Bulletin - November 2011 - Barbados Association of Medical

Transcription

BAMP BULETIN4for pdf 12/29/11 10:21 AM Page 1
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C O N T E N T S
BAMP BULLETIN – October / November, 2011
EDITORIALS
QEH – A Political Football?
Reflections on Mandatory CME for Physicians
FACULTY OF MEDICAL SCIENCES
New Appointmment
COMMENTARY
Are we training too many doctors?
- Professor David Rosin
MEDICAL EDUCATION
Lessons Learned: A Six Country Tour of Medical
Schools: Implications for the Caribbean.
- Dr. Priscilla Richardson & Dr. Alafia Samuels
SPECIAL ARTICLE
World Diabetes Day 2011
- Professor Unwin & Professor Hennis
RESEARCH ARTICLE
The Health of the Nation:
The most detailed assessment to date of
cardiovascular risk in Barbadian adults.
- Christine Howitt, Angela Rose & Professor Unwin
CME ARTICLE
The faces of diabetes in Barbadian children.
- Dr. Michele Lashley
CME / REVIEW ARTICLE
Management of Hypertension in the Caribbean.
- Professor Henry Frase
PERSONAL VIEW
My time at the Grand Old Lady on Jemmott’s Lane
- Arthur Edghill
HISTORY OF MEDICINE
Gray’s Anatomy – A tale of two Henrys.
- Professor John D. Stewart
Changing Medicine, Changing Mentality:
Conventional Versus Alternative Medicine:
The Saga Continues.
- Kim Morris
LETTERS TO THE EDITOR
Pursuing Specialist Registration for all
Family Physicians
Concerns in Relation to the developing Epidemic of
Obesity and Chronic Non-Communicable Diseases
Among Children in Barbados - What can we do?
INSTRUCTIONS TO AUTHORS
COVER PHOTO:
Jamaican Sunset
- Dr. Maisha Emmanuel
Notes From
The Editor
This fourth and final issue of the new Bulletin is rich in content, with
emphasis on Continuing Medical Education (CME), the chronic
noncommunicable diseases of hypertension and diabetes, and
fascinating history of medicine.
We lead with two editorials. The first, perhaps a little tongue in cheek,
but expressing decades of comments and complexities surrounding the
Queen Elizabeth Hospital, is a comment on the on going debate over the
Queen Elizabeth Hospital’s redevelopment, and the options of
refurbishment with addition or a new “green field site” for a brand new
hospital. The editorial points out the likely time frame of such projects.
The second editorial addresses the issue of mandatory Continuing
Medical Education, which Medical Council has decided to fly in the
face of world-wide tradition and re-brand as Continuing Professional
Education. We acknowledge that as the second oldest profession
physicians are proud of their professional base, philosophy and practices,
but there is a voluble concern over such a name change, and several
colleagues have compared it with the move in some parts to change our
patients to clients! BAMP is pleased that CME is finally mandatory,
and although proposed nearly 30 years ago, one might say
philosophically that good things are worth waiting for. The “devil is in
the details” however, and clearly a great deal more discussion must take
place, and much more work must be done on this “project in evolution”.
We invite members to join in the discussion in our “Letters to the
Editor” forum.
With the focus on CME, we include a full Review / CME paper on
Management of Hypertension in the Caribbean, a CME paper by
Dr. Michele Lashley on The faces of diabetes in Barbadian children, and
a Special Article by Professor Nigel Unwin and Professor Anselm
Hennis on diabetes, to mark World Diabetes Day.
In our History of Medicine section we have a delightful paper Gray’s
Anatomy – A Tale of two Henrys, by Professor John Stewart, neurologist
alumnus of UWI at Mona, Class of ’69, and retired Professor of
Neurology at McGill. This is followed by another History of Medicine
prize- winning essay
Then there’s a thought provoking article by Professor Rosin on the
large number of doctors being trained by the University of the West
Indies, with some 300 per class at Mona, Jamaica, and more than 200
per class at St. Augustine in Trinidad. The Cave Hill Campus / QEH
took the firm decision in starting the new campus, to better serve
Barbados and the OECS, to limit class size to an absolute maximum of
90, with 25 Barbadian funded students and the remainder Caribbean and
International… in fact class sizes have remained around 60, although to
be cost effective a few more non- national students are needed! Professor
Rosin raises the debate of ? doctors for export.
And finally, we have a gem of a Personal View by retired surgeon and
UWI Gold Medallist, Mr. Arthur Edghill, reminiscing on the Old Lady
of Jemmott’s Lane! We invite other such Personal Views.
We remind contributors to consult the Instructions to Authors at
the back, for the style of your submissions.
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EDITORIAL
QEH – A political Football
BAMP fully supports the Government and the Ministry of Health
in providing the best health care facilities in Barbados, and it would
certainly be wonderful either to have a brand new hospital built
for the 21st century, or a refurbished one with a new state of the art
block – whichever we can find the funds for, in these terrible
times of recession, and with the many complex issues that face the
decision makers. And to temper our impatience about the final
solution, we must recall that the QEH took 16 years from the
recommendation to build, in the Royal Commission of 1948, to
completion in 1964! So no option is a quick fix, and certainly not
a Christmas gift, but possibly a decade away from a firm, informed
and pragmatic decision, which inevitably will require further
consultations and informed discussions.
Happy Independence and Happy Christmas to all our members,
families and patients!
Football is defined as a game with a large, round, inflated leather
ball and two sides each trying to move it across the opponents’ goalline by kicking or other permitted means. Another definition is:
“A person or thing continually kicked or tossed or bandied about.”
(The two-volume Shorter Oxford English Dictionary). Wikipedia
defines a political football as “a political topic or issue that is
continually debated but left unresolved. The term is used often during
a political election campaign ...” It goes on: “There are many
reasons that an issue may be left unresolved. Examples are:
• The issue may be highly controversial with the populace rather
evenly split on both sides. In this case, a government has no clear
positive action to take.
• A government may want the opposite of what the majority of
the people want. By not making a decision, the government
creates time to attempt to convert the public opinion.
• Government may be split on a decision and neither side is
willing to give in to the other.
• A minority group in government may be opposed to a decision
and will use a method to delay a decision, such as a filibuster.
• Politicians may be attempting to draw the issue into public
debate in order to gain their own popularity at the polls.”
Reflections On Manditory
CME for physicians
The new Medical Profession Act (2011-1) requires “all registered
medical practitioners, under section 18, to renew their registration
annually with presentation of evidence of “Continuing Professional
Education [CPE] as approved by Council, Section 18 [2].”
While it should be noted that the medical profession in Barbados,
through its professional association BAMP, has been calling for this
for decades, and are pleased that action has finally been taken, there
are nevertheless some concerns about the “devils in the details”, and
a wide range of points are being raised by members of BAMP, for
clarification of many issues.
The first and most obvious one is purely semantic, but a
significant one – the name CPE. It’s like insisting that patients are
not patients but clients, and doctors are not doctors, with all the
traditional roles and responsibilities, but simply (and verbosely)
registered health care providers, like any other service provider!
CME is no longer CME, it’s been transmogrified by 1984
new-speak into CPE ...
Two other issues are perhaps of greater significance. The first is
the responsibility for accreditation of CME and the evaluation of the
value for credits. A small country like Barbados always has the
challenge of balancing the ideal with the pragmatic, but the response
to the Medical Council having the task of assessing and accrediting
CME programs (sorry, CPE / CME) AND assessing and approving
or not approving the individual’s performance, has been eloquently
expressed as “Council is judge, jury and executioner!”
The Medical Council as the agent for re-licensure is required to
provide guidelines for these new re-licensure requirements to its
constituents and provide a structure and process for providers of
CME to follow. (e.g. 20 credits /year and 60 hours within a three
year period. The Council appears to be the agent which, through a
very small Sub-Committee, will both outline criteria for these
courses or programmes, vet and provide approval (or not) for the
required courses, assign credits by an as yet unexplained process,
and then assess physicians on their submissions.
In the Weekend Nation of Friday, November 4th, political
columnist Albert Brandford explored many of the above issues that
have made the decision about the QEH so difficult. He wrote:
“First, we had the new Jerome Walcott hospital. Then, the new
David Estwick hospital. Then, the refurbished David Thompson
hospital. Now, we have the new Donville Inniss hospital; a pledge
in 2008, a withdrawal of that promise also in 2009; and now, the
latest version of a promise in 2011 … we all live in hope of getting
a better, new hospital – or not!”
Editorial Committee:
Dr. Wayne Clarke (Chairman)
Professor Henry Fraser (Editor)
Professor Anne St. John
Professor George Nicholson
Dr. Ingrid Durant
Dr. Maisha Emmanuel
Dr. Joseph Herbert
Dr. Cindy Flower
Advisory Board
Professor Mike Branday
Professor Ian Hambleton
Professor Trevor Hassell
Dr. Carol Jacobs
Professor Patsy Prussia
Professor Nigel Unwin
Professor the Hon. E.R.Walrond
Professor Vijay Naryansingh
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E D I T O R I A L . . . cont’d
At this time, requirements have been spelt out very broadly and
somewhat vaguely – e.g. “certified participation / attendance at
conferences, symposia, online courses, etc. approved on the
recommendation of the sub-committee , 1 – 15 credits each”.
This is very broad, and it’s not yet clear how they will be evaluated.
The statement that subscription to a journal is worth only a single
credit is surprising – while it is possible for a subscriber not to
ever read his journal, the wealth of information in the good family
practice journals must be worth more than that! And what about
the BAMP Bulletin? And what about specialists? Their needs
require considerable further discussion and clarification.
These are just some of the issues that merit further detailed
consideration, as we move towards a fair and sensible way of
achieving quality CME practices and the highest quality of patient
care. There is much room for discussion, to sort out the details, and
there are considerable precedents to work with, both internationally
and regionally, including those of our CARICOM neighbours in
Jamaica. And both the Medical Council and the University will have
to increase the human resources to handle the demands created.
As this is a new mandate, it would behove the Medical Council to
consider and address the following international best practices as regards
to CME of physicians:
Best practice dictates that a body separate from both provider and
Medical Council be allocated this function, as to do otherwise can be seen
as a potential conflict of interest. The Barbados Accreditation Council
may be a potential agent for this purpose, but examples from countries
with longer traditions are instructive. For example the College of
Family Practitioners of Canada performs this role, and their Mainpro
programmes “focus on quality and/or performance improvement. These
programmes are designed with the needs of a specific target audience in
mind and are implemented using learning methodologies that
promote reflective practice and continuous quality improvement.” (CFPC
Website).
The Accreditation Council for Continuing Medical Education
(ACCME) sets and enforces standards in physician continuing education
(or ‘life-long learning’) within the United States. It acts as the overseeing
body for institutions and organizations providing continuing medical
education (CME) activities (ACCME Website). The Council comprises
seven member organizations : the American Board of Medical Specialties
(ABMS), the American Hospital Association (AHA), the American
Medical Association (AMA), the Association of American Medical
Colleges (AAMC), the Association for Hospital Medical Education
(AHME), the Council of Medical Specialty Societies (CMSS), and the
Federation of State Medical Boards (FSMB). In other words this is
an independent body formed with representation of the professional
providers of CME, together with the Federation of State Medical Boards.
“The ACCME sets standards and certifies that institutions and
organizations meet those standards. "CME credit" is part of special
programmes offered by other organizations (e.g. the American Medical
Association) and is not the purvue of the ACCME … A voluntary
self-regulated system and a peer-review process are used to regulate and
accredit medical education providers.
In the UK and Ireland the Royal Colleges perform a similar role to the
ACCME in relation to the universities and BMA, but also provide their
own courses, and the Medical Council merely acts as judge, rather than
accreditation body and jury!
In small countries such as Barbados, where there are limited numbers
of providers and of “experts” in the respective fields, there is always
a challenge when a new body is proposed, but it would appear that the
experience of larger countries should be instructive. The BAMP and
UWI/FMS should be recognised as the official “providers of CME” in
the country – a role they have played, in partnership, for more than 30
years. All courses/lectures offered for CME credit should be offered under
their auspices.
Rather than a small Sub-Committee of Council, the options would
include strengthening the College of Family Practitioners, or an
independent Committee, possibly but not necessarily under the umbrella
of the Barbados Accreditation Council, comprising a significant range
of senior professionals. This Accreditation Committee would decide on
the allocation of credits, i.e. Category I, Category 2, and make provision
for both within the mandate, decide on the value of various types of CME
and on the required number of each as requirement for re-registration;
and decide on the reciprocity of international courses accredited by
international associations. For example, courses accredited by the
Royal Colleges in England and by the AMA in the US might be given
automatic approval.
Faculty of Medical Sciences:
NEW APPOINTMENT
Dr. Charles Taylor trained as
a physician, endocrinologist
and diabetologist in the
United Kingdom (UK)
after graduating from the
University of the West Indies.
Following the award of
a
national
Barbadian
scholarship he joined the
medical
faculty
and
completed the MB BS.
He achieved membership of
the Royal College of Physicians and completed specialist
training at Kings College Hospital London. He also
completed an MSc in Diabetes and Endocrinology at
King’s College University London, as well as a post
graduate diploma in Medical Education.
As a specialist research fellow in inpatient diabetes care
he sat on the steering group of the National Diabetes
Inpatient Audit (NaDIA) and worked with the national lead
of inpatient diabetes care. Dr. Taylor’s research interests
include inpatient diabetes care, approaches to the education
of patients and health professions on diabetes management,
and self directed learning of medical students.
Dr. Taylor is a Senior Lecturer in Medicine at the
University of the West Indies Cave Hill and will also work
as an honorary consultant of the Queen Elizabeth Hospital.
When not at work he is focused on trying to interpret
the coded communication of his one year old son, with the
able assistance of his wife.
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C O M M E N TA RY
Are we training too many doctors?
Professor R. David Rosin
MS,MB,FRCS,FRCS(Ed),FICS,FCCS,FIAS,DHMSA
Professor of Surgery, Faculty of
Medical Sciences, UWI Cave Hill
Campus & Queen Elizabeth Hospital,
Barbados.
One of the greatest problems in
medicine world-wide is that no country
has truly worked out their medical work
force needs. Some have tried & failed
(The British Association of Urological
Surgeons), not surprisingly, with
increasing technology resulting in less
need for some specialists. We need look
no further than cardiac surgery; in the early 1990s with increasing
numbers of patients needing cardiac by-pass operations the NHS
in the United Kingdom deemed it necessary to train many more
cardiac surgeons. Not long after, the cardiologists commenced
coronary artery stenting with a dramatic reduction in the number of
coronary artery by-pass grafts needed.
The more sophisticated & “civilized” we become, it seems we
develop new problems, such as morbid obesity, almost unknown to
our parents’ generation, which has created a new specialty, bariatric
surgery, now a recognized subspecialty in Europe & the USA.
At the same time, third world countries are plagued by the diseases
of malnutrition & common infections.
First world countries should be net exporters of medically trained
personnel, but the reverse is actually true. Third world countries,
which can ill afford to lose their doctors & nurses, are, in fact,
net exporters - bizarre, but not that surprising when one analyses
the reasons.
A Headline from San Diego (1) caught my attention a few months
ago: “Training Doctors as Shortage Looms”. A third of physicians
are due to retire in the USA within the next decade. To counter
this, medical schools have been slowly expanding, although the
“burden with debt” (the average medical student owes $160,000 on
qualifying) is causing a fall off in applications, but residency
programmes have not been expanding. As Medicare provides the
revenue for postgraduate training, which has now been capped, there
will be huge shortages, especially in Primary Care. By 2020
there will be a shortfall of 91,000 doctors in the USA, 50% in
Primary Care.
Another article (2) entitled “Countries without doctors shows
that there is a net “brain drain” to the USA. Some 25% of practising
doctors & 28% of residents in the USA, a quarter from India &
Pakistan, which are listed by the WHO as having Health Care crises,
are from abroad. There are more Ethiopian doctors in Chicago than
the whole of Ethiopia, a country of 80 million people!
Another headline reads: “Canada needs thousands of doctors
now” (3) while in Australia a Crisis Summit has been called to
discuss training of interns & specialists, as increasing medical school
places, together with the acceptance of international students in large
numbers, has occurred without any increase in internships (4).
Finally, there is a paper entitled “Shortage of Doctors in a Health
System in Crisis” (5) from South Africa. There are 27,400 doctors
& specialists for South Africa’s 50.5 million people & most of these
practise in the cities. At present 1,400 are trained each year but 25%
leave the country. The WHO (6) estimated that 57 countries have an
absolute shortage of 2.3 million health care workers, focusing on
physician shortage.
So what happens in the Caribbean? I submit that we produce too
many doctors for our own needs and will be producing even more
in the future. Therefore we are a net exporter. The Mona campus in
Jamaica & the St. Augustine campus in Trinidad have doubled their
numbers of medical students over recent years, with 300 per class at
Mona and nearly as many at St. Augustine, while the Cave Hill
campus in Barbados, with its new preclinical school, has gone from
25 to the 60s, although the number of Barbadians is limited and the
total remains very modest compared to its sister campuses. Like the
USA there is an anxiety about internships, although hopefully
facilities in other East Caribbean countries will improve to allow
these regional students to be undertaken in their hospitals.
International students will intern in their home country or elsewhere,
as for St. Augustine’s international students. Cuba has been &
increasingly is a net exporter of doctors, although with a different
training background. And there are a large number of “off-shore”
medical schools in the Caribbean, also turning out doctors, largely
for the USA.
So it would seem we could have a problem – especially Jamaica
and Trinidad. Should the Caribbean be training doctors for export,
to work in sophisticated hospitals / clinics in 1st world countries, or
give them broad basic training for practice in less developed
Caribbean islands? Or, indeed, should we perhaps be following the
Chinese example of training “bare-foot” doctor? In fact do these
Primary Health Care Workers (PHCWs) need to be doctors?
Could not a technician or “consultant” nurse / nurse practitioner treat,
for instance, malaria/diabetes/common infections & even perform
minor surgery and suturing?
With this in mind, do the UWI Faculties of Medical Sciences need
to consider 3 different training programmes both in medical schools
& in the postgraduate years? Programme 1: A truncated course of 23 years for Health Care Professionals more qualified from present
day nurses & technicians who would work in country areas of 3rd
world countries. Programme 2: A broad-based programme, similar
to our present course at the UWI, for those who intend to practice
“at home” in 2nd world countries. And a third programme for those
who see their future abroad in 1st world countries. This latter course
could be shorter, more focused & specialized.
The place of anatomy in the undergraduate curriculum is being
seriously questioned. Potential orthopaedic surgeons see no reason
to learn about the inner ear, whilst ENT surgeons feel learning about
the knee joint is irrelevant. The same could be said of physiology
& pathology. One could envisage the “Bare-foot” doctors’
programme incorporating only surface anatomy & bones; the
broad-based course learning about the whole body in an “oldfashioned” way, not needing to understand CT/MRI/Ultra-sound
anatomy, whille those students destined for export would learn basic
“joined-up anatomy” as a basis, but learn their specialised anatomy
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C O M M E N TA RY . . .
pertinent to their chosen specialty during their postgraduate training.
Physiology & pathology could follow the same pattern.
Immunology, for instance could be omitted from Programme 1, be
basic in Programme 2 & be more in depth for Programme 3. I will
not go into minutiae but hope this will give some idea about how
radical thinking could change Medical School education.
Postgraduate training, after an internship, which I believe should
last 2 years & rotate the new doctor through all the major specialties
- medicine, surgery, obstetrics/gynaecology/paediatrics & some
minor specialties depending on which programme the student is
following; e.g. dermatology would be very useful to Programmes
1& 2, whereas Intensive Therapy Unit would be vital for those
following Programme 3. After these “Foundation Years” the
Programme 1 “bare-foot” doctors would go off to practice.
Programme 2 doctors should take up a job in a specialty they believe
they would like to follow for a minimum of a year & then enter a
postgraduate 4-6 year (depending on their chosen specialty) training
programme with an exit examination that ensures they are able to
work as independent practitioners. For instance they would train as
“general surgeons” able to undertake the emergency work as well as
do basic elective surgery in most sub-specialties of what was
general surgery. In medicine there is need of training for a well
rounded general physician rather than / as well as a cardiologist or
endocrinologist. These generalists will have rotated through
subspecialty firms in their hospitals so they will have been exposed,
for example in surgery, to vascular, gastro-intestinal, paediatric,
plastic, breast & laparoscopic surgery. They will know their
limitations when it comes to more difficult/rarer conditions which
they will refer to larger centres.
And the “Export doctors” will enter specific specialty
programmes - -e.g.orthopaedic surgery, urology etc. In medicine it
would be for example cardiology, gastroenterology etc. Having completed their specialty training programme, once they had obtained
a position in a 1st world country they might undertake a fellowship
to super-specialize. The specialties are becoming super-specialized
so that now for instance instead of a specialist in ENT surgery there
is a rhinologist or an otologist who might further super-sub specialize
as a cochlear implant surgeon. The tongue in cheek description of
a USA breast surgeon being only a right or left breast surgeon
may yet happen!
The vexed question of who does the emergency work in 1st world
countries needs to be answered. Does one have, for instance in
surgery, 6 or 7 specialists on call or should one train emergency
surgeons to deal with emergencies. In the USA where there is enough
work to justify such a specialty, there are trained “trauma surgeons”.
However, in Europe where, at least at the present time, penetrating
trauma injuries are uncommon, there is no such specialty. I believe
elective & emergency surgery & medicine should be separated.
Possibly a few large centres doing emergency work & high
technology procedures should be established with their own outlying
elective units for elective work – at least in first world countries.
This would allow elective work to progress unhindered by
unexpected emergency admissions. Trainees would need to rotate
through both the “hub & spokes” centres to obtain training in both
disciplines unless one decided to divorce elective & emergency
doctors. This could work if one practiced “damage control” surgery,
cont’d
allowing the super specialists to take over the patient the
following day.
I have probably ended up posing more questions than providing
answers, but hope this article will provoke a lively discussion as to
which direction training should be taking, especially in the Caribbean.
Before finishing I should like to add my own ideas for further
modifications in the future (7). With the blurring of specialties, it is
difficult to differentiate between a surgeon, interventional radiologist
& therapeutic endoscopist in many situations nowadays; the days of
working in silos is ending. Much of surgical palliation has been taken
over by non-surgical “interventionalists” while diagnostic imaging is
being performed by non-radiologists. The following suggestion will
not be welcomed by those institutions which wish to continue to rule
in their own domains, but I truly believe the time has come to
introduce “Common Stem Training”. This would change the
approach in almost every subspecialty from one that is driven
anatomically to one that is disease oriented.
I envisage training in gastroenterology (e.g.medicine/surgery/
endoscopy & radiology), vascular sciences, neurological sciences,
oncological sciences, locomotor diseases, cardiological sciences,
endocrinological diseases, nephro-urology etc. This Common Stem
Training would take place after the 2 year internship/foundation years
& last 3 years. At the end of this time the Doctor, for instance in
neurological sciences, could decide to specialize in neurology,
neuro-surgery, neuro-anatomy or neuro-radiology. The same
would occur for the other disease orientated Common Stem Training
Programmes.
Revolutionary, but I believe inevitable. We must work in teams
which will be multidisciplinary & these would be best served by
Common Stem Training. This is just starting in vascular sciences
& neurological sciences. Vascular surgeons are performing more
& more procedures which are radiological (EVAR & angioplasties)
while radiologists work in operating rooms & appear to be surgeons.
Perhaps the editor will allow me to write the follow up to this
article on “The Way Forward in Medical Training-Common
Stem Training”.
References
(1) Powell J. Training Doctors as Shortage Looms. San Diego Union
Tribune, July 9, 2011.
(2) Tulenko K. Countries without Doctors. Foreign Policy. Oct. 2,
2011 based on an article written June 11, 2010.
(3) Kamloops V. Health Crisis-Canada needs thousands of Doctors
now. 2011. www.kamloopschamber.ca
(4) AMA. Crisis summit called to discuss training of interns &
specialists in Australia. MJA Careers, Nov 1, 2010
(5) Benehu X . A shortage of Doctors – a Health System in Crisis..,
Sept. 17, 2011
(6) Scheffler PM, Liu JX, Kinfu Y & Del Poz MR. WHO
Forecasting the global shortage of physicians: an economic& needs-based approach. 2008. Bull. World Health Organ.
86: 516-523B
(7) Rosin RD. Surgical Training at the Crossroads. 2005, Intl. J. Surg.
3; 11-16.
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M E D I C A L E D U C AT I O N
Lessons Learned:
A Six Country Tour of Medical Schools: Implications for the Caribbean
Dr. Alafia Samuels
Faculty of Medical Sciences,
UWI Cave Hill
Dr. Priscilla Richardson
UWI Cave Hill
The three year old “Full Faculty” of Medical Sciences will
undergo its 3 year regional CAAM accreditation review in March,
2012. In three years the Cave Hill faculty has expanded the 3 year
clinical programme to a full five year undergraduate curriculum,
inaugurated graduate programmes in Public Health, recruited
international faculty and attracted some of the best and brightest
students in the region.
The upcoming Accreditation Review motivated Dr. Richardson
(Director of Medical Education) and Dr. Samuels, (programme
director for the MPH programme) to embark on a six country tour in
order to assess and share best practices in medical education.)
The two faculty members arranged interviews with medical
education and public health leaders in the following countries:
England, Scotland, India, Thailand, Hong Kong and Korea (See Note
at end for medical schools visited). They met with Medical School
Deans, Programme Coordinators, Medical Educators, Researchers
and Public Health officials in these countries during a four week tour
in August, 2011.
The objective of the tour was to validate educational strategies in
curriculum design and assessment; to assess and share international
best practices; and to look for innovative strategies and alliances that
can promote excellence in clinical practice and public health.
costly tertiary care. Small island countries could benefit from a more
strategized approach to disease prevention, including early screenings,
health promotion programmes and training.
Medical Education Reform is…well forever…
Medical Education appears to have more cache in other regions.
The trend in Medical Education to standardize physician
competencies and assessment strategies has created the need to
accommodate education specialists in the medical programmes.
Physician migration patterns have placed more demand on certifying
exams. Countries visited have medical educators on boards and in
some instances medical education and assessment centers to provide
guidance in these areas. The trend for institutional and programme
accreditation has also placed a burden on most medical programmes
to assess, evaluate and report on curriculum matters, which has
many countries importing education specialists from abroad.
The Caribbean could take advantage of these regulatory demands
to place more value on educational pedagogy that integrates with
traditional regional patterns of training.
Synergy of Education, Research and Clinical Care
In Scotland and India there appears to be a focused synergy in
which research informs training, and training maximizes clinical
competence and care. The Caribbean could maximize its impact on
disease if resources were allocated to more focused research efforts,
especially in the areas of demonstrated disease burden, such as
diabetes, cardiovascular disease and hypertension. (This approach is
already part of the philosophy of the Chronic Disease Research Centre
at the Cave Hill Campus.) The research could then inform curricular
reform in regional epidemiology and public health training, and
physicians and other health care personnel would be more
effective practitioners.
Some Lessons Learned
Size matters
Implementing best practices in medical education depends largely
on available resources. Small island countries benefit from resource
planning and audits that inform how best to plan for and allocate
scarce resources, including physician specialists
The Economic Burden of Disease is a great motivator
In India, with a population of 1.2 billion, the burden of “economic
blindness” is so great, that over 3.5 million cataract surgeries are
performed annually. In addition, the government sponsors research
and outreach programmes in this area. Economics drives education
and research in this area. The Caribbean could certainly focus more
on prevention and health promotion in the area of diabetes and
obesity. Economically disadvantaged and developing nations have
adopted the public health perspective of the 1978 Alma Alta
Declaration …i.e., Primary Care focus on disease prevention.
Some industrially advanced countries (Korea and the USA) are
going bankrupt curing one person at a time, concentrating on the best,
Partnering with Government is a good thing
In order to create a “healthy nation”, to reduce the burden of disease, to prevent disease and promote health, governments need to
work as partners with the healthcare providers, institutions and researchers. It is ironic that in smaller countries, these partnerships are
limited and often non-existent. Hospitals, universities, ministries and
polyclinics would benefit from stakeholder meetings to strategize
health promotion and disease prevention more effectively.
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epidemiology and a public health focus is essential as physicians are
training in one country and often practising in another. We need to
embrace regional and international best practices and integrate them
so as to graduate physicians who are “fit for practice” anywhere in
the world.
Partnering with Industry is an even better thing
The University of Hong Kong’s Li Ka Shing’s Faculty of Medical
Science is a resource rich campus. Administration buildings,
teaching and research labs are fully equipped as is the state-of-the
art library. The faculty buildings are newly refurbished thanks to
the generous support of the local racing organizations. It is a good
thing that the local racing community has undertaken such a large
project. The University is proud of this partnership, as are the donors
who sit on the advisory board and whose name appears on all
buildings and collateral signage.With scarce resources in small island
countries, it is even more advantageous that regional universities look
to community partners for support. These relationships can also help
provide the needed vision and expertise so often lacking.
If you don’t have it…import it
Most of the campuses visited displayed a decidedly
international faculty.
These institutions made focused efforts at importing members of
the knowledge team that they needed to create centers of excellence.
This takes vision and the will to assimilate and encourage change
in the service of excellence, while developing and strengthening
local skills.
Think Globally…Act Regionally
Best practices in healthcare and medicine demand international
collaboration, evidence-based curricula, integration of technology,
and a fostering of life-long learning. The inclusion of global and a
B A M P
Medical Schools visited: England (king’s College); Scotland (Stirling University,
Glasgow Caledonia University); India (AIIMS Medical and Research Institute),
Thailand (Rangsit University); Hong Kong ( Li Ka Shing Faculty of Medicine and
Korea (Kyungpook National University & Graduate School of Public Health).
2 0 1 1
SPECIAL ARTICLE
World Diabetes Day 2011:
Staying optimistic despite the unrelenting rise in numbers
Professor Nigel Unwin,
Professor Anselm Hennis,
BA, BMBCh, MSc, DM, FRCP, FFPH
MBBS, PhD, FACP, FRCP
Professor of Public Health and
Epidemiology, Faculty of
Medical Sciences,
Cave Hill, University of the
West Indies, Bridgetown
Professor of Medicine and Epidemiology
and Director, Chronic Disease Research
Centre, Faculty of Medical Sciences,
Cave Hill, University of the West Indies
Correspondence to
[email protected]
Professor Nigel Unwin trained in General Medicine and Public Health.
He joined the Faculty of Medical Sciences last September as Professor of
Public Health and Epidemiology, moving from his previous post of
Professor of Epidemiology, and co-Director of the WHO Collaborating
Centre for Diabetes, at the Newcastle University, UK. He previously spent
two years as a medical officer with the diabetes group at WHO Headquarters.
His major interests are in the epidemiology, public health impact and
prevention of chronic diseases, particularly diabetes. He is an experienced
teacher and supervisor at undergraduate and postgraduate levels.
November 14th 2011 marks the 120th anniversary of Frederick
Banting's birth. Banting, a Canadian , received the Nobel prize in
medicine in 1923 for his key role in the discovery of insulin a
year earlier (1). The use of his birthday as World Diabetes Day
(WDD) began in 1991, a joint initiative between the International
Diabetes Federation and the World Health Organization
(WHO) (2). The day was inaugurated with the recognition that
diabetes was a rapidly growing global health problem, affecting all
countries at all levels of economic development. Since 2007 the day
has been an official United Nations world day, following the UN
resolution on diabetes in December 2006 which recognised diabetes
as “a chronic, debilitating and costly disease associated with major
complications that pose severe risks for families, countries and the
entire world.” Around 90 to 95% of all diabetes is Type 2, the
majority of which is thought to be preventable. So, 20 years on from
the first WDD and the recognition of diabetes as a global problem,
what is happening to rates of diabetes and our ability to take effective
preventive action?
Tracking the global diabetes epidemic
It is a 'no brainer' to state that good data are needed to guide and
evaluate preventive interventions. Yet many countries do not have
population based data and estimating the prevalence of diabetes
requires extrapolation, from countries with data to those without,
and extrapolating over time where the data are old. In 2009, for
example, the International Diabetes Federation (IDF) was only able
to identify 5 countries out of 24 in the Caribbean with their own
national data - and all of these studies were over 5 years old (3).
Much good work has been done in the Caribbean (4), but there is
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S P E C I A L A R T I C L E . . . cont’d
need in many countries for more up to date studies.
This year has seen the publication of two new major studies
estimating the global prevalence of diabetes in adults. The Global
Burden of Disease study used Bayesian statistical modeling to
estimate mean fasting glucose and diabetes prevalence for adults
(25 years and above) from 1980 to 2008 in 199 countries and
territories (5). They could not identify any population based data
for 92 countries. The IDF, in the 5th edition of its Diabetes Atlas
has estimated the prevalence of diabetes in adults aged 20 to 79
years. It uses a systematic, rule based approach to identify the most
appropriate study to use for each of 216 countries and territories based on considerations that include geographic proximity, ethnicity,
and economic level.
The Global Burden of Disease (GBD) study (5) estimated that
in 2008 there were 346 million men and women aged 25 years and
over with diabetes globally, making up 9.8% (95% uncertainty
intervals, 8.6 to 11.2%) and 9.2% (8.0 to 10.5%) of the male and
female populations respectively. They estimated that in 1980 there
were 153 million people with diabetes, and that 70% of the increase
since then is due to population growth and population aging, but
that 30% represents a real increase in age specific rates, largely due
to worldwide increases in obesity.
The IDF Atlas (6) estimates are consistent with those from GBD,
suggesting that in 2011 there are 366 million men and women with
diabetes aged 20 to 79 years, with a global prevalence in this age
group, men and women combined, of 8.5%. The two regions with
the highest prevalence are North America and the Caribbean, and
the Mediterranean & North Africa, with 10 to 11% of adults affected
respectively (figures age adjusted to the World population). Of the
10 countries or territories with the highest prevalence, 4 are Pacific
Islands, and the other 6 are in the Middle East, in which prevalence
ranges from 19 to 26%.
Both studies indicate that the vast majority (around 80%) of
people with diabetes live in low and middle income countries. The
IDF estimates that the age adjusted prevalence of diabetes in high
income countries is 7.9% compared to 8.6% in low and middle
income countries. In fact, in upper and lower middle income
countries diabetes prevalence is higher in every age group than in
high income countries, with the exception of those aged over 65
years in lower middle income countries.
The IDF, in collaboration with the WHO, also estimates the
proportion of deaths attributable to diabetes (6,7). Diabetes as an
underlying cause of death is known to be poorly recorded on death
certificates, so a modeling approach is used to provide more realistic
estimates. These illustrate the significant impact diabetes is having
on mortality the world over. In North America & the Caribbean
region, for example, (see figure), between 1 in 5 and 1 in 10 deaths
in adults aged over 40 are attributable to diabetes.
Possibilities for prevention and even reversal of Type 2 diabetes
A large proportion (WHO optimistically estimates 80%) (8) of
Type 2 diabetes is preventable through the avoidance of obesity and
the maintenance of physical activity. This statement is supported by
a large body of observational epidemiological data and a good
number of randomised controlled trials in those at high risk of
developing diabetes (9) i.e. with impaired glucose tolerance or
impaired fasting glycaemia..
Once Type 2 diabetes has developed, the vast majority of
evidence to date has suggested that its normal course is one of
persistent deterioration, with a steady rise in blood glucose and a
fall in pancreatic beta cell function (10). Ten years after diagnosis
more than 50% of individuals require insulin therapy (11). However,
reversal of Type 2 diabetes has been described, such as in obese
individuals undergoing bariatric surgery(12). A new study published
this year demonstrated that a calorie restricted diet used by
overweight individuals with Type 2 diabetes within the first 4 years
of diagnosis, may also normalize blood glucose. In addition, this
study demonstrated recovery of beta cell function. These changes
were associated with a marked reduction in liver and pancreatic
triglyceride levels (13) – hypothesised to be the key changes leading
to decreased hepatic glucose output and improved insulin secretion.
Targeting individuals at high risk and population
wide approaches to prevention
Given the evidence cited above, much attention has been
directed at identifying and intervening on individuals at high risk
of developing Type 2 diabetes. However, there is little evidence to
date that it is possible to get even close to replicating the results of
well resourced randomised controlled trials of diabetes prevention
in the 'real world' (14). Even if it is was possible, the benefits at a
population level would be relatively small. As many as 50% or more
of individuals who develop Type 2 diabetes move rapidly through
the prediabetes stage and so would not be identified for preventive
interventions (15). Intervening to reverse diabetes once it has
developed, although theoretically possible in some individuals, is
even less feasible within everyday health care settings.
It is clear that significantly reducing the incidence of Type 2
diabetes will require measures that reduce the level of risk factors
across the entire population. Guidance on the prevention of Type 2
diabetes published this year from the UK National Institute of
Health and Clinical Excellence emphasised the importance of
population wide measures to promote healthier diets, increase
physical activity and reduce obesity (16). One example of the action
required is ensuring that promoting physical activity becomes a
primary objective of transport policy, in the design of new buildings
and in planning the wider built environment.
Prevention and the United Nations High Level Meeting
on Non-Communicable Diseases
In large part inspired by the Port of Spain Declaration on NCDs in
2007, the United Nations held its first ever High Level meeting
dedicated to the prevention and control of Non-communicable
diseases in September of this year. This is only the second time in
its history that the UN General Assembly has met on a health issue
(the last issue was AIDS in 2001). The document agreed to at
the meeting (17) strongly emphasises the need for population wide
interventions that employ education, legislative, regulatory and
fiscal measures. It also emphasises the need for international
cooperation in reducing the risk of NCDs. This is particularly
important in an era of globalisation for risks that are promoted by
transnational corporations and conditions of trade. Transnational
food corporations, for example, are a major source of foreign direct
investment in low and middle income countries, and can have a
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S P E C I A L A R T I C L E . . . cont’d
huge impact on diet.
Although strong on rhetoric the resolution arising from the UN
High Level Meeting on NCDs has been rightly criticised for being
short on specifics. It completely lacks targets for implementing
change. Rather, the resolution asks WHO to produce
recommendations by the end of next year for a set of voluntary
global targets on the prevention and control of NCDs.
11.Prospective Diabetes Study Group UK. Overview of 6 years’
therapy of type II diabetes: a progressive disease. UK Prospective
Diabetes Study 16. Diabetes 1995;44:1249-58.
12.Taylor R. Pathogenesis of type 2 diabetes: tracing the reverse route
from cure to cause. Diabetologia 2008;51:1781-9.
13.Lim EL, Hollingsworth KG, Aribisala BS, Chen MJ, Mathers JC,
Taylor R. Reversal of type 2 diabetes: normalisation of beta cell
function in association with decreased pancreas and liver
triacylglycerol. Diabetologia 2011;DOI 10.1007/s00125-0112204-7.
14.Simmons RK, Unwin N, Griffin SJ. International Diabetes
Federation: An update of the evidence concerning the prevention
of type 2 diabetes. Diabetes Research And Clinical Practice
2010;87:143- 9.
15.Unwin N, Shaw J, Zimmet P, Alberti KG. Impaired glucose
tolerance and impaired fasting glycaemia: the current status on
definition and intervention. 2002;19:708-23.
16.National Institute for Health and Clinical Excellence. NICE public
health guidance 35. Preventing type 2 diabetes: population and
community-level interventions in high-risk groups and the
general population Ordering information. London: National
Institute for Health and Clinical Excellence; 2011.
17.United Nations high-level meeting on noncommunicable disease
prevention and control. 2011. (Accessed 15/10/11, 2011, at
http://www.who.int/nmh/events/un_ncd_summit2011/en/
index.html.)
Where will we be in another 20 years?
So, 20 years on from the first World Diabetes Day, what progress has
been made? Despite big improvements in understanding the
epidemiology, pathogenesis and prevention of Type 2 diabetes, its
prevalence is higher than ever and it is a growing cause of morbidity
and mortality in virtually all countries of the world. If World Diabetes
Day 2031 is to report real progress in the prevention of Type 2
diabetes, there will need to be a sea change from environments which
foster unhealthy diets, physical inactivity and obesity to those which
support healthy lifestyles and population well-being. This will
require strong national and international leadership and initiatives
that engage all sectors of government and society. The Caribbean
led the way to the United Nations High Level Meeting on
NCDs; can it now help to lead the way from the rhetoric to effective
prevention?
Declarations of Interest
Nigel Unwin is co-Chair of the committee producing the Diabetes
Atlas of the International Diabetes Federation, and Anselm Hennis
is a member of that committee.
Flower Show
References
1. Bliss M. The discovery of insulin. Toronto: McCelland and
Stewart; 1982.
2. Diabetes Programme. 2011. (Accessed 15/10/11, 2011, at
http://www.who.int/diabetes/en/.)
3. International Diabetes Federation. Diabetes Atlas: fourth edition.
Brussels: International Diabetes Federation; 2010.
4. Hennis A, Fraser HS. Diabetes in the English-speaking
Caribbean. Rev Panam Salud Publica 2004;15:90-3.
5. Danaei G, Finucane MM, Lu Y, et al. National, regional, and
global trends in fasting plasma glucose and diabetes prevalence
since 1980: systematic analysis of health examination surveys
and epidemiological studies with 370 country-years and 2·7
million participants. Lancet 2011;378:31–40.
6. International Diabetes Federation. Diabetes Atlas: fifth edition.
Brussels: International Diabetes Federation; 2011.
7. Roglic G, Unwin N. Mortality attributable to diabetes: estimates
for the year 2010. Diabetes Res Clin Pract 2010;87:15-9.
8. World Health Organization. Preventing chronic diseases: a vital
investment : WHO global report. Geneva: World Health
Organization; 2005.
9. Gillies CL, Abrams KR, Lambert PC, et al. Pharmacological and
lifestyle interventions to prevent or delay type 2 diabetes in
people with impaired glucose tolerance: systematic review and
meta- analysis. BMJ 2007;334:299.
10.Kahn S. The relative contributions of insulin resistance and
beta-cell dysfunction to the pathophysiology of type 2 diabetes.
Diabetologia 2003;46:3–19.
Two little old ladies were sitting on a park bench outside the
local town hall where a flower show was in progress.
The older one leaned over and said, ''Life is so boring.
We never have any fun anymore. For $10.00 I'd take my
clothes off and streak through that stupid, boring
flower show!''
''You're on!'' said the other old lady, holding up a
$10.00 note.
The first little old lady slowly fumbled her way out of her
clothes and completely naked, streaked (as fast as an old
lady can) through the front door of the flower show.
Waiting outside, her friend soon heard a huge
commotion inside the hall, followed by loud applause and
shrill whistling.
Finally, the smiling and naked old lady came through
the exit door surrounded by a cheering, clapping crowd.
''What happened?'' asked her waiting friend.
''I won $1000 as 1st prize for '
Best Dried Arrangement'.''
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RESEARCH ARTICLE
The Health of the Nation:
The most detailed assessment to date of cardiovascular risk in Barbadian adults
Ms Christina Howitt, BSc, MSc
Project Manager
Chronic Disease Research Centre,
University of the West Indies
Ms Angela Rose MSc
Co-Principal Investigator
Chronic Disease Research Centre,
University of the West Indies
For further information please contact Ms Christina Howitt:
[email protected]
Prof Nigel Unwin BA, BMBCh,
MSc, DM, FRCP, FFPH
Co-Principal Investigator
Cave Hill Campus, University
of the West Indies
The participants for the study are being recruited with the help
of the Barbados Statistical Service. A multistage sampling process
is being used, starting with enumeration districts, then
households, and then one adult per household. Two thousand
adults aged 25 years and over will be studied. The goal is
to achieve a sample that is representative of the adult population
of Barbados.
It is well known that Barbados has high rates of cardiovascular
disease and diabetes, and that a major public health priority is the
prevention and improved control of these conditions. It is perhaps
surprising to learn, therefore, that the prevalence of diabetes in
Barbados is relatively poorly known, with current estimates being
largely based on good but somewhat outdated studies (1), such as
Barbados Eye Study (2). Even less is known on the levels and
distribution of several key risk factors for diabetes and cardiovascular
disease, and still less on their economic impact. Effective prevention
and control activities require good data in order to identify key risk
factors and population groups, and to monitor the impact of
interventions. The Health of the Nation Study (HotN) is designed to
meet this need. The study is being undertaken by the Chronic
Disease Research Centre and the Faculty of Medical Sciences at
Cave Hill. Primarily funded by the Ministry of Health, the HotN has
received additional funding from Mr. A. Bynoe for the investigation
of renal disease, and there is also significant collaboration with the
Medical Research Council in Cambridge, UK, for investigation of
physical activity levels. The study will provide the most detailed
assessment to date of cardiovascular risk in Barbadian adults, and
began data collection in September this year.
Data Collection
All data are being collected at participants’ homes by trained data
collectors. Data collected on all participants by interview include
demographic and socioeconomic details, lifestyle factors,
diagnoses of diabetes and hypertension, and amount and places
of contact with the health care system over the past 12 months.
Anthropometric and blood pressure measurements are taken at
the time of the interview. Nurses return the next morning to take
a fasting blood sample, analyses on which include lipids, glucose,
glycated haemoglobin, and creatinine.
In addition to the core study, which includes all 2,000
participants, two studies are being conducted on sub-samples.
One sub-study is designed to accurately measure sodium
intake in adults aged 25 to 64 years. For this, 400 adults will
be recruited and will collect 24 hour urine samples for the
measurement of sodium content, in addition to a nutritional
questionnaire to investigate the main dietary sources of
sodium for Barbadian adults. A second sub-study will objectively
measure physical activity in 600 adults aged 25 to 54 years.
Physical activity will be measured using a state of the art
monitor known as ‘Actiheart’, which is a combined motion
sensor (accelerometer) and heart rate monitor (see photo).
Participants in this study will wear the monitor for a week.
Study Aims and Participants
The overall aims of the HotN are in adults aged 25 years and over:
1. To investigate the prevalence, age, sex and socioeconomic
distribution of diabetes, cardiovascular disease and associated
behavioural and biological risk factors;
2. To estimate the annual cost of healthcare;
3. To use data collected to identify potential targets for
interventions to improve the prevention and control of diabetes
and cardiovascular disease in the Barbadian population.
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R E S E A R C H A R T I C L E . . . cont’d
estimating cost of healthcare use in general, the costs of treating
stroke and myocardial infarction in Barbados can be estimated.
Feedback to Study Participants
All participants will receive a written copy of their results, including
body mass index, blood pressure, glucose and lipid values. They
will be advised as to whether the results are normal, or whether
they should seek medical advice. Where urgent medical advice is
indicated, for example where blood glucose is very elevated, they
will be contacted in person by a member of the study team.
The Future of Health of the Nation
This study will provide invaluable information for directing health
promotion and health care activities. It is planned that it will be repeated at regular (e.g. 5 yearly) intervals, to monitor trends in risk
factors and thus help evaluate the success of preventive actions.
New Information for Barbados and the Caribbean
The HotN has several novel aspects that will add new knowledge
to support the prevention of diabetes and cardiovascular disease in
Barbados, as well as the wider Caribbean.
• The first objective measure of sodium intake in Barbados.
Commonly used questionnaire approaches to assessing sodium
intake suffer from large errors and biases, and hence the gold
standard, recommended by the World Health Organisation and
others, remains 24 hour urine collection(3). Data on 400 individuals
will provide a precise enough estimate of population level sodium
intake to allow the impact of the current campaign to reduce sodium
intake to be monitored.
• The most robust estimate of diabetes prevalence to date, based
on both fasting blood glucose and on HbA1c. In most populations
there are around as many people with undiagnosed as with
diagnosed diabetes (4). HbA1c has recently been accepted by both
the American Diabetes Association and the World Health
Organization as a valid diagnostic test for diabetes, so long as
laboratory support exists to provide high quality, internationally
aligned, HbA1c assays (5).
• The first population-based assessment of the prevalence of
dyslipidaemia in Barbados. Total and HDL cholesterol, and
triglycerides will be measured, and LDL cholesterol derived from
the Friedewald formula.
• The first population based objective measure of physical
activity. All participants in HotN will complete a questionnaire on
physical activity, and this is useful for finding out the different types
of activity that people do. However, questionnaire data for physical
activity (as for diet) are known to be poor at quantifying the amount
of activity – there is just too much error in most people’s
responses (6). The use of the Actiheart in HotN will provide the
best estimates to date for the Caribbean of the contribution of
physical inactivity to diabetes, hypertension, and other aspects of
cardiovascular risk.
• An estimate of the prevalence and distribution within the
population of renal impairment, based on measuring serum
creatinine and urine albumin to creatinine ratio. This will help to
target efforts to reduce the growing burden of renal failure that
Barbados is currently facing.
• Last, but by no means least, data on the frequency and type of
contact with health services over the past year on all participants
in HotN will be linked to a study investigating health care costs for
stroke and myocardial infarction survivors. In this way, as well as
The Study Team
The principal investigators on the study are Ms. A. Rose (who
is also leading the work on healthcare cost) and Professor N. Unwin
(who has undertaken similar studies in several settings). Ms. C.
Howitt is the project manager, and is also leading the work on
physical activity. Other core members of the study team include
Professrs A. Hennis, I. Hambleton and C. Landis, Ms. A. Browne,
Dr. K. Ojeh, Ms. G. Pitts and Dr. K. George. Mrs. R. Harris is
leading the work on salt and nutrition. Professor T. Hassell and
Dr. A. Samuels have provided valuable guidance and support.
Glucose is being measured in the Barbados Reference Laboratory,
whose Director, Mr. E. Gibson, is a study co-investigator.
Most important is our team of trained data collectors who will be
travelling the island to collect the data from participants. They are:
N. Archer, M. Ford, K. Grannum, D. Knight, T. Phillips,
G. Reece-Walcott, C. Shearman, and J. Wilson.
References
1. Hennis A, Fraser HS. Diabetes in the English-speaking
Caribbean. Rev Panam Salud Publica 2004;15:90-3.
2. Hennis A, Wu SY, Nemesure B, Li X, Leske MC. Diabetes in
a Caribbean population: epidemiological profile and
implications. Int J Epidemiol 2002;31:234-9.
3. Elliot P, Brown I. Sodium Intakes Around the World:
Background document prepared for the Forum and Technical
meeting on Reducing Salt Intake in Populations (Paris 5-7th
October 2006). Geneva: World Health Organization; 2007.
4. International Diabetes Federation. Diabetes Atlas: fourth
edition. Brussels: International Diabetes Federation; 2010.
5. World Health Organization. Use of Glycated Haemoglobin
(HbA1c) in the Diagnosis of Diabetes Mellitus: Abbreviated
Report of a WHO Consultation. Geneva: World Health
Organization; 2011. Report No.: WHO/NMH/CHP/CPM/11.1.
6. Warren JM, Ekelund U, Bessond H, et al. Assessment of
physical activity – a review of methodologies with reference
to epidemiological research: a report of the exercise
physiology section of the European Association of
Cardiovascular Prevention and Rehabilitation. European
Journal of Cardiovascular Prevention and Rehabilitation
2010;17:127–39.
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RESEARCH ARTICLE ...
cont’d
Overview of core HoTN data:
1.
Demographic and socioeconomic information
2.
Smoking
3.
Alcohol consumption
4.
Nutrition
5.
Self- reported hypertension, along with blood pressure measurements.
6.
Self-reported diabetes, along with fasting plasma glucose and HbA1c measurements
7.
Self-reported dyslipidaemia, along with liquid profile measurements.
8.
Self-reported renal disease, along with creatinine and microalbumin measurements.
9.
Self-reported cardiovascular disease, sickle cell disease, asthma and COPD or emphysema
10. Measures of obesity (BMI, waist and hip circumference)
11. Cost of healthcare, access to services and quality of life
Physical Activity Sub-Study:
• Self-reported physical activity
• Objective measures of physical activity (Actiheart)
Nutrition Sub-Study:
• Sodium intake
• Measures of intake of other dietary micronutrients
THE AMBER LIGHT
The light turned amber, just in front of him. He did the right thing, stopping at the crossing , even though he could
have beaten the red light by accelerating through the intersection.
The tailgating woman was furious and honked her horn, screaming in frustration, as she missed her chance to get
through the intersection, dropping her cell phone and makeup.
As she was still in mid-rant, she heard a tap on her window and looked up into the face of a very serious police
officer. The officer ordered her to exit her car with her hands up.
He took her to the police station where she was searched, fingerprinted, photographed, and placed in a holding cell.
After a couple of hours, a policeman approached the cell and opened the door. She was escorted back to the
booking desk where the arresting officer was waiting with her personal effects.
He said, ''I'm very sorry for this mistake. You see, I pulled up behind your car while you were blowing your horn,
flipping off the guy in front of you and cussing a blue streak at him. I noticed the 'What Would Jesus Do' bumper
sticker, the 'Choose Life' license plate holder, the 'Follow Me to Sunday-School' bumper sticker, and the
chrome-plated Christian fish emblem on the trunk, so naturally...I assumed you had stolen the car.''
Priceless.
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CME ARTICLE
The Challenges Of Managing Diabetic Youth in Barbados
Dr. Michele Lashley, MBBS (UWI), DM (UWI)
Paediatrician & Lecturer in Child Health, Faculty of Medical Sciences, UWI, Cave Hill, Barbados
were 29 new cases admitted to the QEH in the previous 10 year
period.(2) However, at the QEH in 2011, 10 new cases so far of
juvenile diabetes have been diagnosed. Five of these new cases of
insulin dependent diabetes - children from age 2 years to 13 years
- have been diagnosed in the last 2 months.
On the weekend of October 1st and
2nd 2011, St. Lucia was the venue for
training workshops in Child Diabetes
care – The theme was: “Managing
Children with Diabetes from Theory
to Everyday Practice” - sponsored
by The International Society for Child
& Adolescent Diabetes (ISPAD)
and International Diabetes Federation (IDF) in collaboration with the
Caribbean College of Paediatricians
(CCP), St. Lucia Medical & Dental
Association, Caribbean Endocrine Society (CARES) and UWI,
Cave Hill, Barbados.
In this valuable and exciting Continuing Medical Education
opportunity, members of the Caribbean College of Pediatricians
and other members of the Child Diabetes management team from
St. Lucia and other islands, had the chance to exchange ideas and
opinions directly with regional and international child diabetes
and obesity experts, and so improve their knowledge of Types 1
and 2 Diabetes Mellitus in children, adolescents and young adults,
and the related problem of child obesity. Participants included
physicians, nurses, nutritionists, health educators and youth living
with diabetes and their parents.
The cost of diabetes
Overall, the global spending on patient care for diabetes is US
$465 billion.(1) In Barbados it is estimated that one third of the
budget for health is spent on NCDs, of which diabetes ranks fourth.
The short-term costs need to be assessed to determine if the
long-term benefit results in lower lifetime costs, taking quality of
life, long-term complications and life expectancy into account
Diabetics and insurance
One of the many problems related to health costs is that
“Diabetes is considered a pre-existing condition and as such would
not be covered under a standard medical insurance policy”. (3)
The insurance companies have stated that the decision for approval
is based on the efficient management of the diabetes. Once this has
been proven, individuals can apply for a medical insurance policy
which would provide coverage for all conditions except for diabetic
related cases. However, if coverage is provided under a group
medical insurance policy all conditions inclusive of the diabetes
will be covered.
This is of major importance for the young diabetic who may be
considered un-insurable if they are not previously covered.
Unique challenges for childhood
In childhood, in addition to the basic challenges of care, the
following issues are specific for the young and often newly
diagnosed child or adolescent (4-8).
The faces of diabetes in Barbadian Children
The scope of the problem
About 366 million people worldwide have diabetes, according
to the latest figures from the International Diabetes Federation
(IDF), released at the United Nations summit on noncommunicable diseases (NCDs) in New York. Of these it is
estimated that there are 60,000 children who have type 1 diabetes
and there is a reported increase in type 2 diabetes in children
throughout the world . The new report also estimates 4.6 million
deaths from the disease annually (1).
In 2004 a ten-year study by Best and St John noted that there
14
•
The Physical, emotional, psychological, social, and intellectual
differences and needs of the developing child must always be
taken into account
•
The balancing of the intake of nutritious food to maintain
growth and development
•
The battle of constantly changing insulin requirements
•
The cost and need for frequent monitoring of blood
glucose levels
•
Physical activity challenges
•
Maintaining a multidisciplinary team approach for both
medical management and diabetes education
•
The concept and implementation of transitional care for
adolescents and age related education re contraception, safe
sex, alcohol and drugs
•
The new challenges of the diagnosis and management of
type 2 diabetes in the youth.
B A M P
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•
- peer pressure when eating foods different from other children
- insulin manipulation by teenagers to achieve weight control
- religious and cultural influences, especially during prolonged
fasting periods
- School meals or school cafeteria choices
- FAST FOODS, which are often laden with fat
- Obesity management; in the background of the family are the
dynamics of the Caribbean family re “fatness”
- Difficulty in accepting that food practices may have led to the
diagnosis of Type 2 diabetes
The prevention of early diabetes type 2 through control of the
“Diabesity” epidemic, noting that the obesity rate has doubled
in Barbados – even among the preschool and early primary
school children. This is reflected in the Barbados Children’s
Health and Nutrition study presented this year which
studied more than 500 9-10 year olds in the primary schools.
This study showed that the overall obesity rate among
both genders was 35.6% (9)
There were 29 new cases of
juvenile diabetes admitted to the QEH
in the 10 years 1995 – 2004, but already 10 new cases in 2011!
Costs of insulin regimens and blood glucose monitoring
Personal expenses for diabetes care vary widely around the world,
with costs prohibitive in some countries and completely paid for
by the state or private health insurance in others. Regardless of
the source of payment for care and information about costeffectiveness, the use of newer insulin regimens and analogues have
increased the cost of care. (12)
Diagnosis challenge for Type 2 in childhood
Who should be screened and by which test?
Researchers calculated that the best HbA1c level for
identifying pre-diabetes was 5.5% (specificity of 59.9% and
sensitivity of 57.0%). In addition, the optima HbA1c threshold for
identifying type 2 diabetes was 5.8% (specificity and sensitivity
of 87.6% and 67.7% respectively). With the low sensitivity and
specificity, the use of HbA1c by itself represents a poor
diagnostic tool for pre-diabetes and type 2 diabetes in obese
children and adolescents.
Insulin management
Barbados is fortunate to have insulin available free of cost;
however insulin storage is sometimes an issue when the child takes
insulin to school. In Barbados only the recombinant Human and
NPH insulins are available on the National Drug Formulary.
The analogue long acting or rapid acting insulins can run up to $20$40 USD per vial. However, both rapid acting and long acting
analogues have been shown to reduce the frequency of mild and
moderate hypoglycemia and as such are now being recommended
in many newer insulin management regimens. Since the cost of
these regimens can be prohibitive, the Diabetes Association of
Barbados has acquired funding to assist children who need the
non-formulary insulin and this has greatly eased some of the
ongoing financial burdens.
Despite this, many patients were not afforded this option as a
result of cost and inexperience with dosing. Unfortunately the lack
of a paediatric endocrinologist in the public sector clinics also
inhibits the use of newer management protocols, as reliance on
management rests solely with the paediatricians
The Definitive Diagnostic test remains
The Oral Glucose Tolerance Test (OGTT)
The OGTT is recommended to be performed when the HbA1c
is equivocal and the risk factors of obese children/adolescents with
a strong family history of diabetes or gestational diabetes are
present, or if there are signs of insulin resistance present such as
acanthosis nigricans, elevated triglycerides and fatty liver disease.
WHAT THEN POSES THE REAL CHALLENGES FOR
MANAGING DIABETIC YOUTH IN BARBADOS?
Education
Diabetes education remains a challenge for some patients and
families. There is still fear and embarrassment, which are often a
hindrance to understanding especially in the lower income families.
The Diabetes Association and the Diabetes Foundation have been
making strides in this regard, but many parents still do not utilize
their free services.
In Barbados it is estimated that
one third of the budget for health
is spent on NCDs, of which
diabetes ranks fourth.
Nutrition
The major challenge is maintaining contact with the dieticians
individualizing food intake and insulin regimes. For many children
with diabetes there may be inappropriate school meal plans and
often inappropriate time allowed for snacks, especially in the
secondary schools.
There is also a lack of appreciation of many age–related
problems, even among some of the medical teams (10,11,13).
These include:
- toddler food refusal,
There has also been an increased use of insulin pumps by many
patients. These newer modalities are not available in Barbados and
some patients travel to the USA (at a total cost of $8-9,000.00)
where they are fitted and return for management under the
care of the local endocrinologists. The pumps also come with
recommendations for increased frequency of blood glucose testing
and increased technical support. (12). Fortunately with the
availability of telemedicine and internet communications, these
challenges are not as formidable.
15
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parents who overprotect them, leading to the “vulnerable
child syndrome” (14).
Physical activity
The importance and challenges of advocating increased
physical activities cannot be overstated. Neighborhood violence
and the lack of play parks in many communities are a constant
threat to outdoor play (10).
In addition, being able to fit in physical activities in the regular
routine of the child of the “digital age” may not be as easy as
stated. Decreasing screen time is of utmost importance, but also
incorporating active video games such as those now marketed for
the Wii can also supplement outdoor sports.
As with all activities monitoring the risk of hypoglycaemia
and balancing the insulin/carb “diet” must play an important role
for the child. The task of educating games and sports coaches to
facilitate children is also a challenge and we need to provide
ongoing physical education support as part of the medical team.
Many patients are encouraged to adopt self- care with respect
to insulin administration but this may lead to risk taking behaviours,
with over / under administration, especially in the adolescent
group.(13) However there is little education in the schools in Barbados or trained nurses to assist the child on an insulin pump, or
the child who may need multiple injections during Barbados or
trained nurses to assist the child on an insulin pump, or the child
who may need multiple injections during the school day. Students
are often closely monitored with their personal records on Saturday
morning on the Paediatric units/ clinics to help facilitate this care
without disruption of the school day.
Monitoring blood sugar levels
Frequent testing is the hallmark of the standards of care.
In Barbados most children are given free glucose meters. However,
frequent testing often requires the use of more strips than the drug
service supplies and novel testing regimens have to be adopted. (7)
It is estimated that a juvenile type 1 diabetic on insulin will test
at least 3 times daily (using 90+ test strips per month) – but only
50 are obtained via the formulary process. If continuous glucose
sensor technology use increases, as it undoubtedly will, this will
also add to the cost of daily care.
Foot care
Our young people think that “Amputations only happen to
old people”. However, many of the foot complications which overwhelming the surgical department start in the young adult and part
of the ongoing management must include “Shoe support” and discouraging the “Barefoot society” that many children, especially in
the rural parishes, still practice.
Psychosocial issues
Parenting Diabetes children - the issues of care also extend to
the parents who themselves often need psychosocial support.
Unfortunately all parents do not take advantage of the monthly
support group offered by the Diabetes Association of Barbados.
Their outlooks, while different, all revolve around the same basic
theme – thriving with diabetes, and advocating for their children
(14). Parents also have access to internet – they want all the new
technologies and many physicians are often challenged with a
parent who has just heard about a new test or insulin regimen.
The team does not always involve a psychological evaluation for
all patients / parents and the physicians underestimate their personal
dilemmas.
In the children themselves, especially the adolescents, there
may be unrecognised depression, anxiety and fears, which may be
difficult to verbalise. Many of these children are then thought to
be rebels and difficult to manage, when they are just crying out for
understanding of their fears. There may be peer pressure - feeling
as if they are different, especially with testing at school and
Screening for complications
Our biggest challenge in managing the youth is the lack of the
comprehensive care program of the diabetic team that exists in
more developed countries. As such, and without the use of
widespread published guidelines, many of our diabetic youth
especially after leaving the care of the Paediatric services, are not
screened for ongoing complications in a consistent manner.
Many children and adolescents being managed by non-endocrine
trained doctors are not offered the routine tests recommended for
managing the disease
Using the standardized guidelines and having access to
comprehensive care should be the norm for all youth and all
physicians need to be sensitized to these standards. Many patients
themselves do not understand the long term risks and some parents
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CME ARTICLE...
cont’d
cannot relate to the concept of disease for life.
These standard guidelines (4) state that:
Most young people with diabetes are seen by the health care
team every 3 months. At each visit, the following should be
monitored or examined:
In summary, the overall challenge is to offer a better life for
our Youth with Diabetes, through education, advocacy and cost
effective medical care.
•
HbA1c, an indicator of average blood glucose control
•
Growth (height and weight)
•
BMI
•
Blood pressure
•
Injection sites
•
Self-testing blood glucose records
•
Psychosocial assessment
(1) Global Diabetes Plan 20011-2021: International Diabetes
Federation 2010. http://www.idf.org
(2) Best V. R., St John M. A. Incidence of Diabetes Type 1 in
Barbados in Paediatric Patients. W I Med J 2004; 53:
(Suppl.3 )
(3) Insurance coverage and diabetes. Diabetes Today, Issue 2;
Feb 2010
(4) Global IDF/ISPAD guidelines for type 1 diabetes in
childhood and adolescence
(5) Best practice guidelines for the management of type 1
diabetes in childhood and adolescence- summary for health
professionals. Queensland Health, Queensland government,
Australia http://www.health.qld.gov.au/publications/
(accessed sept 2011)
(6) NHS NICE clinical guideline CG 15- July 2004 Type 1
diabetes – diagnosis and management of type 1 diabetes in
children, young people and adults
(7) Brink S., Lee W.R.W., Pillay K., Kleinebreil L. Diabetes in
children and adolescents - a basic training manual for health
care professionals in developing countries
(8) Clinical practice guidelines: Type 1 diabetes in children and
adolescents: Australasian Paediatric endocrine group for the
department of health and aging.
(9) Fernandez M., Kubow K. et al. A snapshot of child
overweight and obesity in Barbados. Obesity 2011; 19
(Suppl 1): S214
(10) Gaskin P., Knight J. et al. Risk of overweight in relation to
parenting behaviors, activity levels and school type in a 9-10
year old cohort : The Barbados children’s health and
nutrition study. Obesity 2011; 19 (Suppl 1): S143
(11) Smart C., Aslander-van Vliet E., Waldron S. Nutritional
management in children and adolescents with diabetes.
Pediatric Diabetes 2009; 10 (Suppl.12): 100 – 117.
(12) Bangstad H.J., Danne T., Deeb L.C. et al. Insulin treatment
in children and adolescents with diabetes. Pediatric
Diabetes 2009; 10 (Suppl. 12): 82 – 99.
(13) Court J.M., Cameron F.J., Berg-Kelly K., Swift P.G.F.
Diabetes in Adolescence. Pediatric Diabetes 2009; 10
(Suppl. 12): 185 – 194
(14) Delamater AM. Psychological care of children and
adolescents with diabetes. Pediatric Diabetes 2009: 10
(Suppl. 12): 175 – 184.
(15) Pihoker C., Forsander G., Wolfsdorf J., Klingensmith G;J.
The delivery of ambulatory diabetes care to children and
adolescents with diabetes. Pediatric Diabetes 2009:
10 (Suppl. 12): 58
References
At separate annual visits care should also include:
• Evaluation of nutrition therapy (Dietician’s visit)
•
Provide ophthalmologic examination (less often on the
advice of an eye care professional)
•
Check for microalbuminuria (once the child is 10 years old
and has had diabetes for 5 years)
•
Perform thyroid function test (for children with type 1 diabetes)
•
Administer influenza vaccination if available
Continuity of care beyond adolescence
Child clinics presently make referrals, but there is no team
approach in one setting for the childhood population to transition
to adult services. There is presently no adolescent clinic but
this is “on the cards”, especially to meet the needs of chronic
non communicable diseases that start in childhood(13,15).
All adolescents need a comprehensive service, with integration
with obstetrics and gynaecology, as the present single weekly
diabetic clinic at the Queen Elizabeth Hospital does not have
staff for all these needs.
Despite our advances we still have many unanswered questions
in relation to continuity of care and services:
• When is the appropriate age for transfer to adult care?
• How do we improve the attendance at these clinics?
Peer led support groups – youth advocacy
Our challenges with care cannot and will not be won until we
have the support of the youth themselves. Peer support groups, like
the one starting under the aegis of the Diabetic Association, will
make a big difference to the lives of youth with diabetes.(13)
These young people share their stories with politicians and
NGO’s to solicit funds and raise awareness about diabetes and
may even influence legislation. They help calculate insulin/carbs
for new diabetics and act as counsellors to inspire other children
at diabetic camps– and all while they’re still teenagers.
THE GAME OF LIFE IS THE GAME OF BOOMERANGS. OUR THOUGHTS, DEEDS AND WORDS
RETURN TO US SOONER OR LATER, WITH ASTOUNDING ACCURACY.
...Florence Shinn
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CME/REVIEW ARTICLE
Management of Hypertension in the Caribbean
Henry S. Fraser, MBBS, PhD, FACP, FRCP
Why is it a problem?
It’s the silent killer and patients rarely appreciate that. We don’t
know we have it unless it’s measured. It rarely causes headaches,
but if patients complain of a headache, and the doctor measures
the pressure and it’s high, it’s often assumed that when the
headache goes away the pressure has gone down and the patient
stops taking the tablets! MOST HEADACHES are due to anxiety
or migraine, a few are due to too much alcohol or other medical
problems, and VERY few to high blood pressure.
But unchecked and untreated, it insidiously damages the
arteries, the brain, the heart, the kidneys, the eyes and so on.
So it’s often only discovered when it’s done the damage.
(An edited and referenced version of a public lecture given for the
Barbados Drug Service on September 15, 2011, and edited for
Continuing Medical Education)
There are many, many reviews of up
to date management of high blood
pressure (1, 2, 3), and many whole
books on the subject . We also have
local Caribbean guidelines created by
the Caribbean Health Research
Council and distributed to doctors
several years ago (4). So this lecture
cannot possibly cover everything that
it takes many volumes and hundreds
of pages to cover. What I will do is to
try to cover the really big issues ….
The issues that puzzle people, and the issues that cause treatment
to fail, because half of the people with high blood pressure FAIL to
get it controlled, and consequently suffer from the complications.
And half of the people who have it don’t know they have it, hence
its label the silent killer.
And I’ll also say a bit about diabetes, which I call the subtle
killer, and obesity, which I call the socially sophisticated killer,
because it’s not silent, it’s not subtle, it’s pretty obvious, but it’s
socially accepted … these are our three big killers, the silent
killer, the subtle killer and the socially sophisticated killer.
And their good friend is high blood lipids ... Together these four
slippery cronies constitute the Metabolic Syndrome, and where
you see one or two of them, you can bet you’ll soon see the others
joining them …
How can we prevent it?
By understanding the causes and taking action
The causes are a varying combination of genetic and
environmental influences. Hypertension runs in families, that is to
say, it’s genetic … but the environment –that is, lifestyle - makes
a huge difference, and I mean huge, because the biggest cause is
being big! The key point is that one may have inherited the genes
for high blood pressure, and there is a theory that the deprivation
our ancestors suffered in crossing the Atlantic under terrible
conditions, with diarrhoea and vomiting, led to many deaths and
survival of the fittest … those who could conserve salt .. and hence
the high prevalence of hypertension in Caribbean people (11). But
the key point is that genetic factors can often be overcome with
a healthy life style. At least seven things contribute to high blood
pressure. The biggest factor is obesity, but the others are too much
salt, too little potassium and fibre in the diet (and these both come
from fruit and vegetables) cigarette smoking, a stressful life style,
too much alcohol and too little exercise. So these are the clues
to prevention and control. The aetiology of hypertension is
extensively covered in many standard texts, but particularly by
Kaplan (12) and in the Handbook of Hypertension (13).
What is hypertension or high blood pressure?
Blood pressure varies from hour to hour and even from minute to
minute, depending on many things that might happen to you during
the day. The ideal value is around 120 over 70, but because there’s
so much variation in healthy people, the accepted cut off point,
above which there is a risk to health, is 140 over 90. And the higher
the pressure, the greater the risk.
Diagnosis – screening, suspicion, and measurements
Too often the diagnosis is routinely made on a single
measurement. Ideally, every adult should be screened and if the
blood pressure is found to be high there should be further
assessment, because a single reading is often not reliable.
There are errors in machines and human errors. If there is noise
about, the sounds can’t be heard and false high readings will result.
If the arm is too fat and the cuff is too small, a false high reading
will result.
If the technique is not skilled and care is not taken, dangerously
high readings are often missed. So several readings are needed
to make the diagnosis. In the QEH Hypertension Clinic three
readings are usually taken - one by the nurse and at least two or
three by consultant or junior colleague.
How do we measure it?
The standard sphygmomanometer uses a column of mercury and
an inflatable cuff around the arm, and it needs skill and training to
measure accurately. The so-called risks of mercury toxicity from
spillage are grossly overstated, and while modern electronic
devices are easy for anyone to use, they are prone to errors, not
always robust, and also need careful use. BUT THE GREAT
THING IS THEY CAN BE USED TO TAKE LOTS OF
READINGS AT HOME, which can assist the physician in decision
making! Home monitoring should be encouraged as it has been
shown conclusively that it is useful both for the initial diagnosis
and the long-term follow-up of treated hypertension (5,6,7).
Who should have their pressure checked?
Everyone, but especially those with a family history of high blood
pressure, diabetes, heart disease and the overweight – because this
is a FAMILY of diseases - the Metabolic syndrome.
How common is hypertension?
In a word, HALF OUR POPULATION OVER 50, 40 % of
everyone over 40, and 30 % of every one over 30… IT”S VERY.
VERY COMMON, (8, 9, 10)
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How often should it be checked?
Hypertension is classified traditionally into mild, moderate or
severe, or Grade 1, 2 and 3 (JNC V & VII) (1). The more severe,
the more often it should be checked; it’s best for patients to have
their own electronic monitor, and the best make of monitor is probably still the OMRON.
But because accurate measurement is so difficult and values
vary so much, the very BEST assessment is with Ambulatory
Blood Pressure Monitoring (ABPM). There are a number of
valuable reviews , including some by our own UWI alumnus and
hypertension specialist Dr. George Mansoor (14, 15) and others
(16). ABPM is a 24 hour record, with about 70 readings taken
around the clock … with a cuff on the arm and a monitor at the
waist … so when the stress of a traffic jam when late for work, or
a quarrel with your spouse raises the pressure, it shows…. When
listening to relaxing music or walking in the moonlight and it goes
down, it shows, and during sleep it normally drops.
This technology can save lives, because many people have a
much higher blood pressure in the clinic or hospital or doctor’s
office than at home - WHITE COAT HYPERTENSION because the medical setting – white coats and hospital atmosphere
and anxiety - all put the pressure up more than other daily activities,
and it can be the case even for the most relaxed people!
Unfortunately, there are few clues as to which patients are likely to
have white coat hypertension, which carries a good prognosis
compared with genuine hypertension. The only consistent
determinant is age, with older people more likely to display it (17).
Without this assessment, many people are over treated.
But ABPM gives us much information in helping to manage
severe high blood pressure. For example, it has demonstrated that
non-dipping, where the blood pressure does not show the normal
drop at night during sleep, is associated with left ventricular
hypertrophy and a worse prognosis, and with obesity and diabetes
(18, 19). ABPM also predicts renal and cardiovascular risk much
better than office blood pressure (20). The QEH is the only public
hospital in CARICOM with this facility, for the past 15 years, and
I was devastated to hear early this year that the service had been
discontinued after my retirement a year ago. I hate to speculate on
the problems arising from its lack for those severe patients most
subject to strokes and heart attacks, and after much effort and many
meetings by my successor Dr. Connell, I understand the hospital
administration has finally agreed to reinstate the service next month
Management:
There are two main strings to management – life style or
non-drug approaches, and medication.
Life style: “Food, activity and behaviour” spell FAB, and I like
to think of this advice as fabulous advice for a fabulous life…..
these three things affect blood pressure, insulin sensitivity and
hence diabetes control, blood lipids and weight loss, and can
transform not just physical health but self esteem, enjoyment of
life, and longevity.
The key word is Food and not Diet. Everyone thinks of diets,
meaning a special plan, specific foods and recipes, and measured
quantities - a regimentation few can follow. By food, I mean
selecting the right KINDS of foods and applying certain principles
.
19
which many may simply see as common sense, but for which we
now have much evidence.
The things that control weight, blood pressure, diabetes and blood
fats, have been proven by many studies to have small effects
individually but big effects when combined … in other words,
individual components help a little, all together they help a lot.
And the success stories in different countries have much in common
– the DASH diet (21, 22) , the Mediterranean diet (23) and the
Okinawa diet (24) are very similar.
The DASH diet stands for dietary approaches to stop
hypertension … D – A – S – H …. It comprises lots of fish for the
main protein source and omega three fish oils, low-fat dairy
products, low salt and lots of vegetables, with fruits, nuts and high
fibre foods; it’s low in fat, especially saturated fats – so avoid
the pork crackling , red meats and refined carbohydrates. The
Mediterranean diet is similar, with fish, olives, olive oil and tomato.
And the Okinawa diet of Japan is similar, especially low in salt,
and produces the world’s oldest people. The single most important
factor here is salt, because many of our people are salt sensitive…
hence the major international effort WASH – or World Action on
Salt and Health.
Take note of the programme of our National Chronic Non
Communicable Disease Commission – the NCN-CDC …. to
reduce salt intake. Everyone will have seen Professor Hassell’s
exhortations on TV to use less salt, and those ads with the huge
amount of salt in some foods… perhaps the ad exaggerates for
effect, but a little pack of an ounce of crisps can contain a quarter
or more … sometimes almost a handful … of our daily salt
requirement! So the message is: Read the label, avoid crisps,
canned food, and too much salted meat … “savour the flavour”
of the food, with herbs instead of adding salt!
There has always been controversy about salt, because
manufacturers believe they have to add lots of salt to improve the
flavour and sell their products, and they’ve been fighting the
evidence just as with cigarette smoking and global warming….
The powerful vested interests employ “spin doctors”, with
powerful pens and vociferous voices to contradict or misinterpret
the evidence.
Salt is key to the problem (25) and that’s one of the reasons why
the thiazide diuretics are so important. And here in Barbados
Dr. Kenneth Connell and Dr. Damian Cohall are involved
in important research on high blood pressure and how our people
handle salt.
Note also I said activity instead of exercise, because some
people hate the idea of exercise, because it reminds them of games
they didn’t want to play, or skipping or push-ups that they weren’t
good at. ANY kind of physical activity will do … and many people
actually grow to like it, once they start. Some people if they have
the urge to exercise lie down until the urge passes! Some people’s
only exercise is pushing the TV remote with their left hand, raising
a fork with the right hand, and pressing the accelerator with the
right foot. Others only run when they “run thuh mout,’bout thuh
naybuh’s business!”
But for people not doing physical work there has to be SOME
enjoyable activity … To swim go to the gym … to walk, to jog,
cycle, skip or dance – and dancing is great … and you can do it
any time of day or night, no equipment needed; or do push ups and
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CME/REVIEW ARTICLE...
crunches at home, on your bed room floor, or in bed! …….no
details need be given here…. But remember, sexual activity
ALONE is not enough!
Or you can use dumbells and a standing bike at home … AT
least, you can walk … alone where it’s safe or with friends,
and remember the adage: “couples who exercise together stay
together”. But swimming or using weights and doing push ups are
what we call resistance exercise … the kind that stops the muscles
from wasting, and produces the “feel good” endorphins in the brain.
And while walking is good, you must do something with your
upper body ….
BUT – the main point about exercise or physical activity is that
in general “the more, the merrier”, within limits, as benefits seem
to plateau (26) … it used to be 20 minutes three times a week ….
But that burns less calories than a hamburger. It’s better than lying
in bed all week, but it’s not enough to do much for your health and
fitness, or to reduce weight. You deserve half to one hour of activity
three to five days of the week.
BUT NOTE – you can have it, like meals, in several portions…
.. some activity in the morning … best for losing weight …. a walk
before breakfast, in lunch hour, and in the evening … park further
away from the supermarket door … move around the house and
office frequently.
cont’d
ALLHAT study has generated some 300 publications listed on
PUBMED, including those authors challenging the data, which
clearly showed the outcome benefits of thiazide diuretics.
Scores of costly randomised controlled drug trials (RCTs) and
papers make this point. They are not only cheap, reliable and well
tolerated, but they more effective than any other drug in people of
predominantly African descent - most of our people – they produce
the best long term outcome, and they actually potentiate other
drugs, so they should be used in our population both as first line
drugs and in combination when two or three drugs are needed to
achieve control. The large evidence base for these statements is
well summarised in the Cochrane Systematic Review by Wright
and Musini (28) and other review articles (29, 30). There is such a
strong consensus on this, in all guidelines, that unless a person has
gout or an allergic reaction, there is no excuse for not using a low
dose thiazide. Indeed the time may come when not prescribing it
might well be considered malpractice.
The problem we face, however, is that there are eight main types
of drugs for treating high blood pressure, many more subtypes, and
nearly a hundred registered different chemical compounds for treating it. Until last year, our National Drug Formulary contained more
than 50 different drugs. Now I know there may be ladies out there
who own more than 50 different pairs of shoes …. And I could give
another lecture on women’s amazing high heeled, pointed shoes
and the damage they do to women’s feet, which Professor Hennis
et al have shown is a major cause of amputations in diabetes ... but
four inch stilettos are back in fashion, with devastating effects
on our women’s feet … but blood pressure is NOT a fashion
statement! And we don’t need a range of 50 or a hundred drugs …
none of us can remember details of the differences between 7 or 8
drugs of the same type.
I therefore applaud the Barbados National Drug Formulary
Committee for cutting our huge selection of drugs in half, from
more than 50 to about 25 – it’s more than enough … and I
congratulate the Minister of Health for supporting the policy ….
It will save the government a fortune, save foreign exchange, and
make life simpler, ultimately, for doctors, pharmacists
AND patients.
Now I won’t say much about the drugs themselves…. Most
Bajans are reluctant even to remember the names of their tablets…
It’s always “the little white tablet” or the “big white tablet” … but
patients should be encouraged to know the names of their tablets
… it could save a life!
I started with the thiazide diuretic which almost everyone
should be started on. The next most important choice for many
patients, that third to half of patients with high blood pressure AND
diabetes, is an ACE inhibitor, to protects the kidney in diabetes …
but remember, it’s only effective in lowering the pressure in our
older patients when it’s taken WITH the thiazide diuretic.
There are many other drugs … beta blockers, working on the
heart and kidneys and blood vessels, and useful in patients
who also have migraine; calcium channel blockers, and there’s little
difference between them – my favourite is long acting verapamil;
centrally acting drugs – the longest acting, and the new, expensive
angiotensin receptor blockers.
Let me say a word about just one of these – the frequently overlooked centrally acting drug reserpine, discovered in India from
Finally, behaviour:
When I see a patient’s blood pressure go sky high, one of
two things has happened…. They’ve either not refilled their
prescription, or ran out two days early, or they’ve had a disaster.
Their mother’s in hospital, son’s in jail, or husband’s died … of
course sometimes, if they didn’t get along, the husband dying may
be a relief !
The point is that extreme anxiety will raise blood pressure, and
we all need to cultivate a spirit of harmony and equanimity ….
To know what we can change, and adjust to what we can’t - peace
within ourselves and peace in the world … love for God, our
neighbour, our partner, our family, friends and feeling good about
ourselves, which we can only get by being at peace with others,
forgiving and helping wherever we can… what our Book of
Common Prayer calls “The peace which passes all understanding
….”
Now, Drug Management and Drug Choices
Drug treatment for high blood pressure is one of the biggest
advances in medicine in the last 50 years – and I mean big …
good drugs and big, big money at stake! The link between what
used to be called hardening of the arteries and strokes and heart attacks has only been recognised for about 100 years. And until the
1950s there was no tolerable drug treatment. The first drugs were
terrible and incapacitated people. But in the 1950s thiazide diuretics were discovered, but for many years the dose was too high, giving rise to several metabolic side effects.
But the modern low dose lowers the pressure without significant
effect on potassium, glucose, uric acid or lipids. And although
these are the oldest effective drugs, a follow up report of
the ALLHAT study has demonstrated that THEY ARE STILL
THE BEST, FIRST CHOICE, AND THE MAIN CHOICE
FOR MOST OF OUR PEOPLE (27). It should be noted that the
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the raufwolfia plant, but it even grows in Barbados. It used to be
used first in “natural” plant extracts, where the dose varied hugely,
and then in tablets at much too big a dose – in fact more for many
years the recommended dose was .25 mg three times daily, more
than seven times the dose that will lower blood pressure! It was
therefore associated with depression and gastric upset, in those
huge doses.
Because reserpine acts on the blood pressure centre in the brain,
the best dose is just a mere 0.1 of a milligram, used in the big
hypertension trials in the USA in the 1960s and 70s, such as the
Veterans Administration Cooperative Study (VACS) (31, 32); this
is because it binds so tightly to the adrenergic neurones storage
vesicles that it has a half-life of several days! (Compare that dose
to that of the most valuable oral diabetes medication, metformin,
which is 500 or a 1000 milligrams.) And because reserpine binds
so tightly to the central control cells, its effect lasts several days…
it’s the ONLY blood pressure tablet that’s long acting… so if the
daily medications are forgotten, reserpine alone will be still acting
next day! That is NOT the case with any other medications …
But because it’s been around for more than 50 years, like the
diuretics, because it’s cheap and not promoted by manufacturers,
it’s falling out of use is a tragic and unfortunate story, especially for
poor developing countries. The full story of reserpine’s “bad press”
through early toxic overdosing at 0.25 mg three times daily, seven
or more times the effective, well tolerated dose of 0.1mg daily, and
its proven efficacy in low dose, has been extensively reviewed (33),
and repeatedly documented (34, 35), including a Cochrane
Systematic Review (36), and particularly in the classic combination
with thiazide (37). The combination has good outcome data, and
as Slim and colleagues point out (35), reserpine “produces
significant BP reductions, and has a very long duration of action,
so missing a dose is less of a problem than with shorter acting
agents”. Its importance for population blood pressure control in
poor countries is also extensively documented and promoted (38).
The Caribbean has a combination product, Combezide L,
which combines low dose bendrofuazide with low dose reserpine,
because they work so well together, and the cost is one tenth the
price of most new drugs. That means you can get the effect of
two drugs in ten patients for the same cost as treating one person
with a new drug costing a dollar. This drug has been the core
treatment for almost all patients referred to the QEH Special Clinic
for resistant hypertension, with great success, and I have no
hesitation in saying that just as a single tablet of Bendrofluazide
2.5 mg is our best first choice drug, the combination Combezide L
is by far our most valuable, safe, well tolerated, cheap and cost
effective two-drug treatment…. and the great majority of our
patients will in fact need two drugs.
Now unfortunately, because this is an old drug and not a new
sexy drug, it’s accidentally gone the way of the ten times
more costly combination drugs (33), and I’m working with the
drug service and Formulary Committee to get it restored to
the formulary.
studies (EWPHE, HEP, SHEP and HYVET) which have shown
that there is benefit, in some cases even in those over age 80,
particularly in prevention of strokes, cognitive decline and dementia, heart failure and a reduction in mortality; however caution must
be exercised in balancing the GREATER risk of side effects in the
elderly, including greater sensitivity to drug effects, with wellbeing
and potential benefits (39, 40). A target of 150 / 90 is an eminently
sensible goal for control.
Adherence or compliance
Now it doesn’t matter WHAT a doctor prescribes… cheap or
expensive, new or old, white tablets or pink, round or heart shaped,
if patients don’t take them! Unfortunately, many Bajans still think
pressure equals headache, and headache equals pressure, so “If the
head doan’ hurt, nuh need to tek the tablet!” But if the assessment
of hypertension is correct, and life style changes and weight loss
alone fail to control it, almost everyone will almost always have to
take the tablets. And for every 20 pounds lost, pressure will come
down 10 millimetres or the equivalent of one less medication!
So the message to reinforce is: TAKE THE TABLETS –
make it a ritual … Some people say they hate taking tablets, yet
they take half a dozen vitamin tablets and costly so-called
neutraceuticals that they see advertised on TV, making someone
rich and patients poor…. And so a word about so-called NATURAL
products…. Luckily most “so-called natural” products touted
by many commercial voices are in fact manufactured, just like
prescribed pills, but characterised by three things… 1. No evidence
that they do what they claim, 2. Little regulation or standardisation
of even the theorised active ingredient or multiple ingredients, and
3. Great uncertainty about other ingredients, because most plant
extracts contain multiple substances… some toxic, but fortunately
most harmless and ineffective.
So when someone reports that they thought their tablets might
have caused them anxiety or loss of appetite or tiredness or
headache – any of the common daily symptoms we so often have
– so they stopped it and bought something “natural” for 50 dollars,
I feel like weeping…. because they sometimes come back with their
pressure “in the sky”, and sometimes with a stroke. So the factors
contributing to poor adherence with medication need to be
understood (See the review by Lewis – reference 40). Each patient’s
issues must be examined and difficulties, anxieties, myths or
impediments to adherence individually explored, in a spirit of
trust and understanding, and often counselling with a family
member is key.
Monitoring, teamwork and responsibility
This is the role of the individual, the family, the nurse and the
doctor. The old fashioned method of medical care is that a blood
pressure is noted to be high, tablets are prescribed, people tire of
taking tablets when they feel well, and they stop. Pressure continues
to climb as people get older, fatter and less active, and when
they turn up at the doctor again, perhaps because of the ’flu or an
accident, things are much worse …
The modern approach should be very different. Blood
pressure should be accurately measured with at least two readings.
In the pre-hypertensive or Grade 1 range, lifestyle factors
should be reviewed, the dangers of risk factors discussed and clearly
Managing the elderly hypertensive
Managing elderly patients with hypertension, where it may
often be only the systolic blood pressure that is significantly
elevated, has long been controversial, but there are now several
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explained, and life style changes introduced, while basic fasting
blood tests for glucose, lipid profile and kidney function are ordered, and urine tested for protein. A diary recording food changes
and exercise should be started.
At review, based on the achieved food, exercise and behaviour
changes (or no changes!) a more intensive counselling should be
done. A dietician referral may be needed, especially for obesity,
unlessthe physician has a special interest, training or experience in
nutrition and dietary consultation; an electronic blood pressure
monitor should be recommended and the patient should
become fully involved in home measurements, which he brings to
the doctor at follow up visits.
To effect food, activity and behaviour changes needs
involvement and support of doctor, nurses, patient AND partner or
spouse, off-spring or parent, especially the person who buys the
groceries and prepares the meals.
And let me dispel completely the myth of a diabetic diet or a
hypertension diet…. A healthy diet, like the DASH diet, should be
everyone’s diet, to PREVENT hypertension and diabetes. And let
me also dispel the myth that all vegetables are expensive… they
simply aren’t – there are ALWAYS cheap cucumbers, beans,
pumpkin and others in season in Barbados …. And you can always
buy five to seven bananas for the price of one tiny bag of chips!
But some myths live forever!
5. Agarwal R., Bills J.E., Hechl T.J. and Light R.P. Role of home
blood pressure monitoring in overcoming therapeutic inertia
and improving hypertension control: a systematic review and
meta-analysis. Hypertension. 2011; 57: 29-38.
6. Stergious G.S., Blitziotis I.A. Home blood pressure monitoring
in the diagnosis and treatment of hypertension: a systematic
review. Am. J. Hypertens. 2011; 24: 123-34.
7. Hodgkinson J., Mant J., Martin U. et al. Relative effectiveness
of clinic and home blood pressure monitoring compared with
ambulatory blood pressure monitoring in diagnosis of
hypertension: systematic review. BMJ. 2011; 343: 80.
8. Foster, C., Rotimi, C., Fraser, H.S., et al. Hypertension,
diabetes and obesity in Barbados: Findings from a recent
population-based study. Ethnicity and disease. 1993;
3: 404-412 .
9. Freeman V., Fraser H., Forrester T. et al. Comparative study of
hypertension prevalence, awareness, treatment and control rates
in St. Lucia, Jamaica and Barbados. J. Hypertension 1996;
14:495-501.
10. Hennis A., Wu S.Y., Nemesure B. et al. Hypertension
prevalence, control and survivorship in an Afro-Caribbean
population. J. Hypertens. 2002; 20: 2363-9.
11. Wilson T., Grim C.E. Biohistory of slavery and blood pressure
differences in blacks today. A hypothesis. Hypertension. 1991;
17 (1 Suppl): 122-8
12. Kaplan N.M., Victor R.G. Kaplan’s Clinical Hypertension.
2009. Pub. Lippincott, Williams and Wilkins
13. Bulpitt C.J. Handbook of Hypertension Volume 20
Epidemiology of hypertension. 2000. Pub. Elsevier.
14. Mansoor G.A., White W.B. Ambulatory blood pressure
monitoring in current clinical practice and research.
Curr Opin. Nephrol Hypertens 1995; 4: 531-7.
15. Mansoor G.A., Ambulatory blood pressure monitoring in
clinical trials in adults and children. Am. J. Hypertens 2002;
15: 38S-42S.
16. Staessen J.A., Asmar R., DeBuyzere M. et al. Blood Press.
Monit. 2011; 6: 355-70.
17. Mansoor G.A, McCabe E.J., White W.B. Determinants of
the white-coat effect in hypertensive patients. J. Hum.
Hypertens. 1996; 10: 87-92.
18. Cuspidi C., Giudici V., Negri F., Sala C. Nocturnal nondipping
and left ventricular hypertrophy in hypertension: an updated
review. Expert Rev Cardiovasc Ther; 2010: 8: 781-92.
19. Eguchi K. Ambulatory blood pressure monitoring in diabetes
and obesity – a review. Int J Hypertens 20101; 2011: 954757.
Epub 2011 Mar 28
20. Goldsmith D., Covic A. Ambulatory blood pressure
measurements in chronic kidney disease. Arch Int. Med. 2011;
171: 1098-99.
21. Appel L.J. Nonpharmacologic therapies that reduce blood
pressure: a fresh perspective. Clin Cardio: 1999L 22
(7 Suppl) III 1-5
22. Lin P.H. Windhauser M.M. Plaisted C.S. et al. The linear index
model for establishing nutrient goals in the dietary approaches
to stop hypertension trial. DASH Collaborative Research
Group. J. Am. Diet Assoc. 1999: 99 (8 Suppl) : S40-4).
A FAB life style
The bottom line is that the responsibility of living a healthy life
style, a “FAB” life style of the right “Food, Activity and
Behaviour”, managing blood pressure, and NOT shortening life
with a stroke or heart attack, or crippling ourselves with an
amputation or blindness, lies with each and every one of us, with
the help of our families … the nurses, the doctors, and the
Ministry of Health can only do so much.
Managing blood pressure is a partnership, like so much else
in life. It’s easy to say “It won’t happen to me”, but unfortunately, it often does. So we must challenge our patients, in a paraphrase of the Book of Common Prayer, to leave the things they
should not touch and do the things they KNOW they should do,
and be able to enjoy every day of a long, healthy and happy life!
References
1. Chobanian A.V., Bakris G.L., Black H.R. et al. Seventh report
of the Joint National Committee on Prevention, Detection,
Evaluation and Treatment of High Blood Pressure.
Hypertension. 2003; 42: 1206-52.
2. Whitworth J.A., World Health Organisation, International
Society of Hypertension Writing Group. 2003 World Health
Organisation (WHO/International Society of hypertension
(ISH) statement on management of hypertension. J.
Hypertension 2003; 21: 1983-92.
3. Khan N.A., Hemmelgarn B., Herman R.J., et al. The 2009
Canadian Hypertension Education Program recommendations
or the management of hypertension: Part 2-therapy.
Can. J. Cardiol. 2009; 25: 287-98.
4. CCMRC. Managing Hypertension in primary care in the
Caribbean. Commonwealth Caribbean Medical Research
Council. Port of Spain. 1998.
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32. Effects of treatment on morbidity in hypertension. II.
Results inpatients with diastolic blood pressure averaging
90 through 114 mm Hg. JAMA 1970;213:1143–1152.33.
Fraser H.S. Reserpine: a tragc victim of myths, marketing,
and fashionable prescribing. Clin Pharmacol Ther. 1996; 60:
368-73.
34. Manyemba J. A randomised crossover comparison of reserpine
and sustained-release nifedipine in hypertension. Cent Afr J
Med. 1997; 43: 344-9.
35. Slim H.B., Black H.R., Thompson P.D. Older blood pressure
medications – do they still have a place? Am J Cardiol. 2011.
108: 308-16.
36. Shamon S.D. Perez M.I. Blood pressure lowering efficacy of
reserpine for primary hypertension. Cochrane Database Syst
Rev. 2009. 7: CD007655.
37. Grievenow R., Pittrow D.B., Weidinger G. et al. Low-dose
reserpine/thiazide combination in first-line treatment of
hypertension: efficacy and safety compared to an ACE
inhibitor. Blood Press; 1997; 6: 299-306.
38. Seedat Y.k. Hypertension in developing nations in sub-Sharan
Africa. J Hum Hypertens; 2000; 14:739-47.
39. Fletcher A., Bulpitt C. Quality of life and antihypertensive
drugs in the elderly. Aging (Milano). 1992; 4: 115-23.
40. Virdis A., Bruno R.M., Neves M.F. et al. Hypertension in the
Elderly: An Evidence-Based Review. Curr Pharm Des. 2011:
Aug. 24 Epub.
41. Lewis L.M. Factors associated with medication adherence in
hypertensive blacks: a review of the literature. J Cardiovasc
Nurs. 2011. July 13 Epub.
23. Perez-Lopez F.R., Chedraui P. Haya J. Cuadros J.L.
Effects of the Mediterranean diet on longevity and age-related
morbid conditions. Maturitas. 2009; 64: 67-79.
24. Willcox D.C. Willcox B.J. Todoriki H. Suzuki M. The
Okinawan diet: health implications of a low-calorei, nutrient
dense, antioxidant-rich dietary pattern low in glycemic load.
J. Am. Coll. Nutr. 2009: Suppl 500S – 516S.
25. He F.J., Jenner K.H., MacGregor G.A. WASH – World Action
on Salt and Health. Kidney International 2010; 78: 745-753.
26. Position stand of the American College of Sports Medicine.
The recommended quantity and quality of exercise for
developing and maintaining cardiorespiratory and muscular
fitness in healthy adults. Schweiz. Ztschr. Sportmed. 1993; 41:
127-37.
27. Einhorn P.T., Davis B.R. Wright J.T. Jr. et al and ALLHAT
Cooperative Research Group. ALLHAT: still providing correct
answers after 7 years. Curr. Opin. Cardiol. 2010; 25: 355-65.
28. Wright J.M., Musini V.M. First-line drugs for hypertension.
Cochrane Database Syst Rev. 2009; July 8(3): CD001841.
29. Chen G.J., Ferrucci L., Moran W.P. Pahor M. A costminimization analysis of diuretic-based antihypertensive
therapy reducing cardiovascular events in older adults with
isolated systolic hypertension. Cost Eff Resour Alloc. 2005;
3:2-11.
30. Kola L.D., Sumaili E.K., Krzesinski J.M. How to treat
hypertension in blacks: review of the evidence. Acta Clin Belg.
2009; 64: 466-76.
31. Effects of treatment on morbidity in hypertension. Results
in patients with diastolic blood pressures averaging 115 through
129 mm Hg. JAMA 1967;202:1028 –1034.
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PERSONAL VIEW
My time at The “Grand Old Lady” on Jemmott’s Lane
Arthur R. Edghill, C.B.E., M.B. B.S. Honours (Lond.), F.R.C.S. (Ed.), F.C.C.S.
(Retired Surgeon of St. Joseph Hospital and Bay View Hospital)
The following excerpts are taken from Robert H. Schomburgk’s :
The history of Barbados, page 128,129 and highlight the very
beginning of the General Hospital.
The photograph of yesteryear’s
medical staff of the Barbados General
Hospital (BGH) published in the last
BAMP Bulletin (July / August, 2011)
has prompted me to recall my
association with that institution
following my graduation in late 1962
from the then University College of the
West Indies (UCWI). Clearly, all who
are depicted in that photograph have
long since passed away and there
remain only a few of us who have in
fact “walked the corridors” of the BGH. Even though time dulls
the memory, I still recall some of the many incidents that occurred
there and that influenced my choice of career.
‘The brightest instance of the benevolent feeling of the
Barbadians is the General Hospital, which owes its existence to
individual zeal and exertions. An Act (3 Victoria, cap. xxvii.) for
incorporating the members of a Society for the establishment and
maintenance of an hospital for the reception and treatment of the
sick poor, passed the Legislature on the 4th of June 1840.
Since that period suitable buildings have been erected, at a cost of
about £3850 sterling, which sum was entirely raised by voluntary
contributions in Barbados and in England. The hospital was
opened for the reception of patients on the 1st of July 1844.
The medical officers of the institution render their services
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P E R S O N A L V I E W . . . cont’d
no AC was present. Indeed doves often nested on the window sills
of the theatres and yet the occurrence of post operative sepsis was
almost negligible.
There was no Central Sterile Department (CSD) and OR nurses
were responsible for the cleaning, packaging and autoclaving of
the surgical equipment. Autoclave equipment bore no relationship
to that in current use and required manual intervention. As interns
we often lent a hand in this regard, powdering gloves, wrapping
instruments individually, etc. Indeed it was for me an opportunity
to learn the names of the various instruments.
At that time the Hospital Manager was Dr. Harold Forde, who
was also the senior Consultant Physician. Also on staff was Dr.
Bertie Graham, Consultant Physician/Paediatrician , Mr. Aubrey
(Jack) Leacock, later Sir Aubrey, Senior Consultant Surgeon, and
Mr. Frank Ward, General Surgeon and Registrar to Mr. Leacock,
to name a few.
But it was the group labeled Visiting Surgeons with whom I
was closely associated. That group comprised Dr. Hal Massiah,
Dr. Lionel Stuart, Dr. Arnot Cato – later to become Chairman of
the Medical Staff Committee and President of the Senate as Sir
Arnot – and Dr. William St John. Some of these are featured in the
old photograph mentioned above. I was appointed as House Officer
to work on their surgical firm. Though not graduates of any of the
Royal Colleges or of other post graduate surgical institutions, they
had acquired surgical skills and competence that were absolutely
essential for their time and they complemented the surgical services
of the two qualified surgeons.
Dr. Massiah was especially keen to manage ruptured ectopic
pregnancies and would respond at any time of day or night to
this emergency. But never a hurried individual, he would arrive in
his Jaguar car wearing his black blazer; there was seldom an air of
urgency. But his technical ability was unquestionable.
About Dr Cato I recall, among other things, his lunch sessions.
His meal was ordered from the kitchen and it was always
accompanied by two bottles of Heineken beer, one of which he
consumed with his meal.
The other was earmarked for his surgical assistant. No other
surgeon was so considerate! When the BGH was replaced by the
QEH, Sir Arnot became Chairman of the Medical Staff Committee
and eventually President of the Senate of Barbados. On his passing
his entire estate was entrusted to a fund in his memory, the Arnot
Cato Trust Fund, to assist the QEH and the medical services of
Barbados and St. Vincent, the latter being the country of his birth.
Dr. Stuart was the perfect gentleman; always neatly attired and
courteous, I do not ever recall him being upset or angry regardless
of the circumstances.
Dr. St. John was the youngest of the Visiting surgeons and was
easy to get along with. When I left to pursue post-graduate
studies he presented me with the Eighth Edition of French’s Index
of Differential Diagnosis and it remains in my collection of
medical works.
gratuitously, and consist of six practitioners of the first standing. A
resident matron and a janitor, with the requisite nurses and domestic servants, are attached to the hospital.
The accommodation at present provided for in-door patients
admits seventy-seven beds, and the annual expenditure may be
stated at about 6000 dollars or £1250 sterling.’
For a more detailed description of the care of the sick and poor
(almost synonymous with slaves) during the seventeenth and
eighteenth century in Barbados, refer to the work of Eleane I.
Hunte, “The Unsung Nightengales” .
Now fast-forward to the year 1953. At the tender age of 15, I
entered the Science Sixth at the Lodge School and immediately
came into contact with Herbert (Wox) Gooding, the Biology
Master. Throughout my four years of his tutelage he expounded
the facts of life with examples from the lowly amoeba to man
himself and I desired to know more. I would pursue the study
of Medicine.
Graduating with other Barbadians from the UCWI at Mona,
Jamaica, at the end of 1962, I and others left Jamaica almost as
soon as the results of the Final MB BS examination were known
and returned to Barbados to intern at the BGH. Together with
Denis Bailey, George Maynard, Belfield Brathwaite, Alfred
Ralston and Robert “Bob” Gaskin (forgive me if I have omitted
others) we became the first batch of UCWI medical graduates to
intern in Barbados. For me this association with the BGH not
only cemented my choice of post-graduate study but I knew
that on the completion of such study, my life’s work would be
here in Barbados.
That I would indeed choose a career in surgery had first taken
root when, as a medical student assisting one of the surgeons at the
UCWI Hospital at Mona with the correction of a hydrocoel, the
surgeon was called away to another theatre to give an opinion.
He uttered one word to me “CONTINUE” - and so I did, with
assistance from the anaesthetist. When later the surgeon returned
he found an empty theatre and I was proud to inform him that the
procedure was completed and the patient was in recovery.
My two years at the BGH then allowed me the opportunity to
work alongside surgeons who were always willing to impart
surgical skills to those with interest and I grabbed this with open
arms. I knew then that I would become a surgeon.
The Barbados General Hospital was at that time the main
hospital on the island; Dr. Bayley’s Clinic was a privately operated
small clinic and hospital. The BGH comprised a number of
buildings some of which were connected by covered walkways.
The main building, now housing the Ministry of Health, was
originally “Carlisle House”, the residence of Colonel Jemmott on
1.5 acres of enclosed land along Jemmott’s Lane. It was purchased
and converted into wards, residences and offices. In time more land
adjacent to the Main building was acquired and other buildings
added. Radiology was housed in a separate small building, as was
the Pathology department. The term ICU was not then heard of.
There were two operating theatres (ORs), the main Veecock
theatre in the building that housed the Prince Albert (male surgical
ward) and the Marie Louise (female surgical) ward. The second
theatre was in the Tercentenary ward. Both theatres were on the
first floor and were naturally ventilated through screened windows;
History Corner - Old General Hospital Staff
Working alongside these gifted GP/Surgeons, performing a variety
of simple surgical procedures, I gained valuable experience and
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basic surgical skills at an early stage of my career. But I also
benefitted from the fact that as family doctors they demonstrated a
warmth and caring attitude towards their patients that might
otherwise be missing. So that when later I returned to Mona to
pursue post-graduate studies I was already prepared with valuable
technical and other skills that soon propelled me to a post of
Surgical Registrar.
As an Intern at the BGH I looked after patients on the various
wards, some located in the main building which until very recently
housed the Ministry of Health. Since visiting surgeons were also
required to manage Paediatric and Orthopaedic cases I looked after
these also. In addition, interns and other junior doctors worked in
the Casualty Department.
Casualties were certainly managed there, but in reality this was
a general practice clinic that was grossly understaffed and always
full of patients. During the day the Casualty was staffed by family
physicians carrying out sessional work. But from 4.00 PM until
whenever, the department was staffed by one of the resident staff
including the interns.
I recall my first such session. I was the sole doctor in the unit
and it was late at night when the nurse handed me a patient’s notes.
At that time, clinical information was hand written on 4”by 6” cards
stapled together and this one was as thick as the Bible. The nurse
who was clearly familiar with this patient advised that the patient,
a female, was here for her regular complaint of abdominal pain for
which no specific cause had ever been discovered. Her treatment
almost always was with the narcotic drug pethidine and it was
suggested that I prescribe the same. Tempted as I was at that late
hour to follow the nurse’s suggestion, I dutifully reviewed her
notes, took a history, performed a physical examination and
recommended a simple analgesic. She looked at me in disgust,
“stupsed” and stormed out of the room. She would be back at
another time, but for the remainder of that night I agonized over
my management. Had I missed a serious abdominal emergency?
Sessions in Casualty were particularly exhausting as one had
worked all day on the Wards or in the OR’s but was expected to
single handedly man the Casualty until all patients had been
managed. This meant that a Casualty session went on to the wee
hours of the morning and if perchance the doctor left to “grab a
rest” he or she was almost always called to return and care for an
emergency. Indeed we had one doctor who had developed his
own style of managing the Casualty. He would report at 4.00PM
and work until dinner time, around 7.00 PM. He could not be
reached until after 11.00PM by which time the last bus had left the
City for the country areas and many of those waiting in Casualty
had chosen to abandon the wait and take the bus for their home.
Those who remained in Casualty, he reckoned, were genuine
emergencies that needed medical attention!
For those were the days of the “back street abortions” and
“Ruptured ectopic pregnancies” many of whom arrived in shock,
hemodynamic or septic or both. One was then expected to
admit these patients and begin emergency management. For those
requiring emergency surgery and the surgeon-on-duty happened
to be one of the visiting surgeons, I was required to be present in
theatre for the procedure. It was in the management of such cases
that I was exposed to the technique of harvesting of peritoneal
blood, its filtration and infusion into the shocked patient. So that
during any 24 hour period an intern/house officer was expected to
care for ward patients, many sharing beds, to attend operating
sessions for elective and / or emergency cases, and after 4.00 PM
to manage the Casualty.
I recall a particularly exhausting casualty session with many
emergencies, all brought in by the Police, whose sirens we came
to dread. After managing these and others it was about 3.30 AM
and I was on my way to my home in Navy Gardens, and was
driving around the Garrison Savannah. I was stopped by a policeman on duty who reckoned that I was speeding! When the officer
realized that I was the doctor he had met in the casualty that night
he apologized and beckoned me to proceed. I was especially careful
an hour later when on my way back to the hospital.
The BGH admitted public and private patients as pertains at the
QEH. But as interns and housemen we were seldom required to
care for the private patient.
The new interns, accustomed as we were in Mona to attending
teaching rounds and other clinical training sessions, soon realized
that the BGH was no “teaching hospital”. So we attempted to
institute Clinico-pathological Conferences. Our first conference
discussed a medical case; it was chaired by Dr. Forde and was well
attended. We the interns were encouraged. A month later a surgical
case was presented, but no senior surgeon attended and I was left
to present the case! Little discussion followed. Our third attempt
failed miserably and no further conferences took place; we were
saddened by this and it became clear that we had to learn from our
own personal experiences.
One such experience when assigned to the Medical wards took
place and remains forever etched in my memory. An asthmatic in
“status asthmaticus” was admitted in the early hours of the morning
and I was responsible for her care. She had not responded to
subcutaneous adrenaline in Casualty and on admission was
extremely distressed and hypoxic. Oxygen via nasal mask was
started and another trial of subcutaneous adrenaline given.
This was ineffective and I promptly set up an IV line and
administered theophylline. With no improvement I administered
IV steroids. There was minimal improvement. Sedation was
required. Recall that I was only an Intern and it was the year 1963;
none of the current treatment regimens were in existence. I needed
help in managing this patient. The physician on call, the surgeon
on call, the anaesthetist on call - none could be reached, despite
repeated calls. I was at my wits end. Steroids were repeated but led
to no improvement. I sat by this patient’s bedside until the break of
day when she expired. I was overcome with grief and also with
frustration over the failure of the system. This was learning the
“hard way”.
My association with Mr. Leacock, the senior Surgeon came
during my second year at the BGH. The consummate general
surgeon, he was required to manage almost any surgical case and
it was under his guidance that I was now exposed to a wider variety
of surgical challenges. Though not always readily approachable,
it was, however, easy to recognize his skill as a surgeon, particularly
when working in the abdominal cavity.
But my association with Mr. Leacock soon ended when he went
on long leave and his place was taken by an altogether different
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instrument tray- and with one deft incision the peritoneal cavity was
opened, in went his gloved hand and out came an ovarian cyst.
He let all in the theatre know that he was most unimpressed with
the clinical diagnosis and proceeded to remove the cyst, dropping
this in the bowl provided. In two shakes the abdomen was closed
and, grumbling in his rather broken English, he left the nurse and
me to apply a dressing.
He had with this one case stamped his authority and set the tenor
that was to mark his theatre sessions. All subsequent lists began on
time and OR nurses were always prepared well in advance.
And yet, when away from the OR, he was a happy, fatherly figure
with impeccable bed side manners and during lunch sessions would
often relate some of his memorable experiences when working in
Guyana. For me his locum ended too soon.
And so it was that I spent two years in a busy general hospital,
exposed to “some of everything” but assured that I would pursue
training leading to a Fellowship in surgery and return to offer my
services to the country of my birth.
surgical master. Dr. Caesar Romiti of then British Guyana acted as
Senior Consultant Surgeon for the duration of Mr. Leacock’s leave.
One of a family of Italian trained surgeons, Dr. Romiti lived and
worked in British Guyana, associated with the Mercy Hospital
where he gained an enviable reputation as a Master Surgeon.
A charming and gracious man, he and I soon struck up a
relationship like “surgical father and son”. Trained in the era when
general anaesthesia was considered more risky than the surgery,
he wasted no time during or between cases. He came with a
reputation of being a “fast surgeon” whose pet procedure was the
“sub-total hysterectomy”.
In preparing his first theatre list I selected his first case from
the mile long waiting list; a case of uterine fibroids. On the morning
of his first theatre session he arrived bright and early and
was scrubbed and gowned waiting for the OR nurses to arrive.
The patient was duly placed on the OR table and anaesthetized and
Dr. Romiti, clearly anxious to demonstrate his surgical skills,
cleaned and draped the surgical site with my assistance. He helped
himself to the scalpel – the scrub nurse was still preparing her
B A M P
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HISTORY OF MEDICINE
Gray's Anatomy: A tale of two Henrys
John D. Stewart, MBBS, FCCP
Lion’s Gate Hospital, Vancouver, Canada
the retina and optic nerve, and then another on the spleen. Both
received prestigious awards and led him to be elected a fellow of
the Royal Society (FRS) at the age of 25. Gray's first book, now
forgotten, was The Structure and Use of the Spleen (1854). Shortly
thereafter he was appointed Lecturer in Anatomy at St. George's.
Henry Vandyke Carter, the son of an artist, was four years
younger than Gray and also
a student at St. George's.
Poor, religious, insecure and
introspective he nonetheless
was a fine dissector and
anatomist and became a brilliant medical illustrator.
Carter was also a diarist and
it is through these writings
that we learn more about
Gray. The two met while
Carter was a student and
Gray employed Carter to
draw many of the illustrations for his treatise and book
Henry Gray
on the spleen. Carter eventually obtained dual qualifications in surgery and as an apothecary
(akin to internal medicine today). In spite of this he was unable, as
were many medical graduates at the time, to find a clinical job. He
took up a studentship at the famous Hunterian Museum at the
Gray's Anatomy, the book that many
of the older physicians amongst us will
recall, was the book we loved to hate.
It simply contained too much detail for
the average student to digest, let alone
remember, so many turned to
slightly friendlier texts such as the
Cunningham series. Undoubtedly the
"bible" of anatomic texts, "Gray's" the best selling medical book of all
time - was first published in 1858.
Continually republished ever since,
the 40th edition appeared 150 years later in 2008.
Who was Gray? Who did the incredibly detailed and often
beautiful illustrations? What became of these men? Why has the
book been such a success?
Henry Gray was born in 1827, ten years before Queen Victoria
ascended the throne. At age 18 he started his medical studies at
St. George's Hospital in London where a state-of-the-art medical
school building, complete with an excellent dissection lab, had
recently been built. By all accounts, Gray was very hard working
and ambitious, winning prizes in surgery. In 1848 he passed his
membership examination of the Royal College of Surgeons and
was appointed to three positions at St. George's: Curator of the
Pathological Museum, Post-Mortem Examiner, and Demonstrator
of Anatomy. Meanwhile he wrote a long and scholarly treatise on
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HISTORY OF MEDICINE ...
Royal College of Surgeons where he honed his anatomical
knowledge and artistic skills. By 1855 he was back at St. George's
making a paltry living as a medical artist when Henry Gray
made him a proposal: would Carter do the illustrations for a
new anatomy book?
Just three years later, in
1858, Gray's Anatomy
Descriptive and Surgical
was published. It contained 700 pages of
lucid, well organized text
and no less than 363
illustrations. Some 77
of these pictures were
copied from and probably embellished from
other books (which were
usually acknowledged),
but most were from
Gray's and Carter's
dissections. The labeling
Henry Vandyke Carter
of the illustrations was a
vast improvement on other texts.
Within a week of publication The Lancet published an
enthusiastic review along these lines: "....there is not a treatise in
any language in which the relations of anatomy and surgery are so
clearly and fully shown." The British Medical Journal soon
followed: "....far superior to all other treatises on anatomy .... the
woodcuts, from the drawings of Dr. Carter .... are excellent - so
clear and large that there is never any doubt as to what is intended
to be represented."
Then catastrophe! A lengthy anonymous review appeared in the
influential Medical Times and Gazette. This was nasty, highly
critical and essentially accused Gray and Carter of plagiarism.
A recent scholarly discussion of this review concludes that these
allegations were unfounded.(1) This review no doubt was very
hurtful to Gray, but had no impact on sales which were brisk.
Nonetheless Gray was more careful about acknowledging his
sources in the next edition.
The following year (1889) the first American edition appeared.
Curiously this has differed from the start from the British version.
It finally went out of print in 1990. Along the way the name was
changed on both sides of the Atlantic to "Gray's Anatomy".
Gray was quick to prepare the second edition that appeared
a mere two years later and allowed him to make corrections and
additions. By this time Carter had left England and the newly added
illustrations were not up to the quality of Carter's. Thus was started
the hodge-podge of different styles of illustrations done by
numerous artists over the decades. None match the finesse
of Carter's.
Henry Gray FRS, FRCS was now approaching the peak
appointment of his career - surgeon at St. George's. Tragically, this
was "snatched away by death".(1) Gray was nursing his young
nephew who was ill with smallpox and succumbed himself at the
age of 34 years in 1861, much lamented by his peers. None of his
papers survive probably because it was a customary public health
cont’d
measure to strip the home of everything and burn it.
What became of Carter is quite a saga. Even before the first
edition was published he had had enough of low paying medical
artistry and enlisted in the Indian Medical Services, becoming an
anatomist at the Grant Medical College in Bombay (now Mumbai)
and also with a clinical practice in a nearby hospital. He had a
tumultuous affair and eventually married a woman who may
already have had a husband and who brought him "misery and
shame".(2) But professionally he had hit his stride. Now in his
forties, he became a medical researcher. He first studied the
condition of "Madura Foot", and speculated but could not prove
(as it later was) that it was caused by a fungal infection.
He did seminal work on leprosy and also on "famine fever"
(relapsing fever) implicating a bacterium (borrelia) transmitted
by lice. After 30 years in India, Carter returned to
England, remarried happily and had two children. He died of
tuberculosis at the age of 65. Throughout all this time he seldom
drew or painted.
Why Gray's Anatomy was such a success is easily explained
by its very systematic approach, the lucidity of the writing, and
the superior illustrations. It completely outstripped other texts and
has continued to do so ever since. Also, the book appeared at the
dawn of modern surgery. Ether had been discovered in 1847,
and chloroform shortly after. Dr. John Snow (of cholera and water
pump fame) was one of the first anaesthetists and famously
used the latter drug for one of Queen Victoria's childbirths.
Operations could now be done on unconscious patients.
Surgeons needed to know their anatomy in exquisite detail
and Gray's with its emphasis on surgical anatomy admirably met
their needs.
The latest Gray's weighs a couple of kilos and has 1465
pages. An unwieldy book, it has certainly moved out of the
undergraduate's library. It has many strong features, for
example, amalgamating classical anatomy with that seen on
various types of imaging. However, the larger question is whither anatomy education? How much does an as yet
undifferentiated budding doctor need to know? Is anatomy
still "the gateway to medicine"? This continues to be widely
debated,(3) and there are no easy answers.
Figure legends
Fig 1. Henry Gray in his early 20's.
One of only two extant pictures of Gray.
Fig 2. Henry Vandyke Carter. Self portrait, date unknown.
References
1. Richardson R. The Making of Mr. Gray's Anatomy.
Oxford University Press, Oxford, 2008.
2. Hayes B. The Anatomist: A True Story of Gray's Anatomy.
Ballantine Books, New York, 2008.
3. Raftery AT, Anatomy Teaching in the UK.
Surgery 2006;25:1-2.
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The Author
Dr. John D. Stewart BSc,MBBS,MRCP(UK),FRCP(C) is a
graduate of UWI ('69). He trained in internal medicine in the UK,
then spent 2 years teaching and working in Kenya before moving
to Canada to further specialize in neurology. He worked in McGill
University teaching hospitals for many years then moved to a
community practice in Vancouver. He is Professor Emeritus
(McGill) and Clinical Assistant Professor (University of British
Columbia). He is the author of Focal Peripheral Neuropathies,
now in its 4th edition.
cont’d
microbiology, molecular biology, genetic and other scientific
hopefuls who seek to create a newer, better drug than the others.
Hence this has resulted in a pharmaceutical world filled with patents
pending, clinical trials and subsequent high costs, associated with
such, being attached to the price of the drug retailed. This creates a
situation where the name brand medication is more expensive than
the generic brand, when such eventually exists and if it does, in
some cases it is not as effective or has more perceived side effects
than the original drug, due to different formulation and such like.
With respect to the aforementioned, the herbal companies have
eliminated any worries the average patient may have about a
man-made product and their pitch is “providing a natural alternative
that has been around for years”. Most persons have the mentality
where “natural” equates to good for the body, with its historical
usage assumed to be proven benefit, thus accounting for the
blossoming industry of alternative medicine.
This essay will elaborate on the ongoing saga between
conventional and alternative medicine and hope to enlighten one
on the truths and half truths of this dilemma.
Traditional, herbal Medicine versus Modern Times & Effect
of Eastern Medicine on the Western World.
The earliest recorded account of herbal medicines came from
China, dating back to 2800BC, the Pen Ts’ao by Shen Nung (5).
Over the next five thousand years, herbal medicine had a chequered
history with a cyclical falling in and out of favour with man.
However, in light of the growing concern about the efficacy and
side effects of many synthetic drugs, herbal medicine has still
managed to develop with time, with many claims as safer and
“natural” alternative.
Shen Nung tasted hundreds of herbs “to test their medicinal
properties” (Han/Cold, Jeh/Heat, Wen/Warmth, Liang/Coolness),
and established oriental herbal medicine. Over the millennia, the
Chinese continued to use themselves as guinea pigs, providing
continual testing of plants for their medicinal properties.
Accumulation of these results strengthened the understanding of
the toxicity, lethal dose and pharmacological categorisation of
herbal medicines.
Although the Chinese recorded their findings for most herbal
medicines used today, clinical trials such as randomised control
trials have not been carried out to objectively determine if such
medicines are truly beneficial. The conventional synthetic drugs
have proven to be superior in this instance, as many trials are
performed and are a prerequisite prior to their general release and
marketing. This is something not required to put a herbal medicine
on the market and thus leading to the distribution of untested and
unregulated herbal medicines and the reluctance of the medical
practitioner to readily accept their use in conventional medicine.
Some of the skepticism associated with the herbal medicines is that
early herbal medicine had a magical component where it was
integrated with spells and rituals. Various forms of disease were
thought to match a particular demon and that certain “aromatics”
had smells to cast away demons. Although some of the
medicine had success, the reason for its success was misunderstood
at the time.
The history of herbal medicine also includes the first Greek
written records of herbal medicine, around the time when
Hippocrates developed the principles of diet, exercise and happiness
Changing Medicine,
Changing Mentality:
Conventional versus Alternative Medicine:
The Saga Continues
Kim Morris, 4th Year Medical Student’s
History of Medicine Essay, 2010
[Ed: This was an extremely thorough and thoughtful prize-winning review
of the history of herbal medicine, presented virtually in its original form,
but with some edits and editorial comments]
Introduction
With the advent of a new decade, vast
molecular advances are being made in
the pharmaceutical arena. However with
progress comes a price, and although the
drugs being produced by the pharmaceutical companies have become more
specific to the disease process, there are
still many side effects that plague them
(1). Many companies have aimed at
minimising these undesirable effects
with maximum benefit but some
consumers / patients are displeased. There is an attitude that the
medication one takes is supposed to make one feel better as opposed
to no change or worse. As a result, the mainstream pharmaceuticals,
or the conventional. orthodox medicines, have been traded in for the
alternatives(2), namely herbal medicines.
Herbal medicines can be considered the cornerstone of
pharmacology because, prior to the development of many synthetic
drugs in the 1950s, such medicines were the most commonly and
often only available remedies. While some proved to be efficacious,
many were ineffective or offered more harm than good (3).
In a society desirous of instant gratification, ranging from fast food,
instant-win scratch cards and automated telebanking machines,
it is no surprise that some patients are displeased when the
prescribed medication fails to work in their eyes. The modern day
human nature is to seek the next best thing and herbal medicines, a
form of alternative medicine, are heavily advertised and have come
into the limelight.
The herbal medicine market has proven to be a lucrative business
and a viable competitor to the conventional pharmaceutical
companies (4). The latter is saturated with organic chemistry,
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cont’d
Hence in the year 2000, the EU legislation advocated that all herbal
medicines be subjected to compulsory clinical testing comparable
to that undertaken for conventional medicines (8). This allowed for
herbal medicine to be licensed. One drawback, however, is that the
specific ingredient in a herb that causes the proclaimed therapeutic
effect is most often not known.
Also there may be more than one ingredient working
cumulatively to create the desired medicinal effect. The components
of the plant may be affected dependent on where it was grown, for
example climate and soil quality, as well as how it was harvested
and processed.
In 1998, the World Health Organisation (WHO) estimated that
80% of people worldwide would rely on herbal medicine for some
aspect of their primary health care. However a 2004 Cochrane
Collaboration review found that some herbal therapies are
supported by strong evidence but are not widely used in all clinical
settings (9). So although there are many studies available proving
the efficacy of some of these herbal medicines, reluctance remains
with the medical fraternity which is still deeply ensnared by the
clutch of the pharmaceutical companies.
as the cornerstones of health. Hippocrates, Greek philosopherphysician, freed medicine from the realm of superstition and magic
and gave it the status of science. Hippocrates’ principles were
followed in Britain by the Myddfai physicians throughout Saxon
times around 500AD. To this day, these techniques are being used
in conjunction with conventional medicine as even the modern day
clinician realises the benefit of the holistic approach when treating
the patient.
In the 1100s, the Arab world began to have a major influence
on medicine and healing practices. Traditional Arabic or Islamic
medicine is also known as Unani-Tibb6 , Tibb meaning medicine
and Unani thought to be derived Ionian (meaning Greek) thus
acknowledging the Greek influence. Its development is due to a
follower of Galen, Persian physician Hakim Ibn, known as
Avicenna in the West. He considered the physical, emotional and
spiritual aspects of health and developed a system of herbal and
botanical medicine. During the 13th to 17th century Unani
medicine had increasing popularity but encountered some setbacks
during the era of British Empire expansion, but it still continued to
be practised by the larger population.
From the 1600s, society began to see the first two tier health
system where the herbs were for the poor whilst the exotics (plant,
animal or mineral extracts) were reserved for the wealthy7. The
latter were often supplied in exquisitely ornate containers and the
more ornate the container, the more expensive the medication. This
as a result still haunts the mentality of society today where there
are persons in the medical fraternity who opt for the conventional
medicine marketed under their brand names with the persistent drug
representatives keeping their products centre stage.
Herbal medicines began to be overshadowed by mineral-drug
based treatments in the 1800s. Methods of chemical analysis
became available and scientists began to extract and modify the
active ingredients from the plant. Later on, the chemists began to
make their own version of the plant compounds thus birthing the
transition of raw herbs to synthetic compounds. However powerful
drugs such as calomel, which was mercury, and laudanum available
over the counter, had serious side effects which were subsequently
documented. There was diminished faith in the “better” medicine
or the conventional medicine of the time. Around this same time,
Albert Coffin pioneered inexpensive herbal medicine using plants
from America and Europe for working class people at his practice
in Northern England. This provided some impetus for herbal
medicine being accepted into the Western world.
The 1900s proved to be a revolutionary period for herbal
medicine.The burgeoning pharmaceutical industry sought to
discredit the herbal medicine by calling it outdated. However,
during World War I, the pharmaceutical drugs were in short supply
and medicinal herbals were extensively used. The comeback of
herbal medicines was short-lived as the post Second World war
period saw a huge expansion in the international pharmaceutical
industry. Over time, the use of herbal medicines has declined in
favour of pharmaceuticals.
Following in the 1950s spanning into the 1990s, there was
growing public concern over the side effects and environmental
impact of the herbal medicines or the so called “wonder drugs”
which were being marketed as natural and purportedly safe.
Cheaper is Better: or is it?
For the past twenty years, in the United States of America,
there has been increasing public dissatisfaction with the cost of
prescription medications, in addition to an interest in returning to
natural or organic remedies that has led to an increase in herbal
medicine use(10). While, in Germany, there are now over seven
hundred plant-based medicines which are readily available and
prescribed by 70% of German physicians thus illustrating how the
mentality of the medical fraternity has changed over the years.
Herbal medicine is slowly creeping onto the prescription pads since
so many patients are demanding this alternative.
The most commonly used herbal supplements include
echinacea (Echinacea purpurea and related species), St. John's wort
(Hypericum perforatum), ginkgo (Ginkgo biloba), garlic (Allium
sativum), saw palmetto (Serenoa repens), ginseng (Panax ginseng,
or Asian ginseng; and Panax quinquefolius, or American ginseng),
goldenseal (Hydrastis canadensis), valerian (Valeriana officinalis),
kava (Piper methysticum), chamomile (Matricaria recutita),
feverfew (Tanacetum parthenium), ginger (Zingiber officinale),
evening primrose (Oenothera biennis), and milk thistle
(Silybum marianum).(11)
• Ginkgo (Ginkgo biloba), particularly a standardized extract
known as EGb 761, appears to produce improvements in
awareness, judgment, and social function in people with Alzheimer's
disease and dementia. Randomized controlled studies assessing the
use of ginkgo supplements for Alzheimer's disease in individuals
older than 65 years have produced positive results.(12,13).
• Kava kava (Piper methysticum) has become popular as a
treatment for anxiety, but recent reports have traced liver damage
to enough people who have used kava that the U.S. Food and Drug
Administration (FDA) issued a warning regarding its use, while
other countries, such as Germany, France, and Canada, have taken
kava off of the market.
However, there is no definitive proof that kava alone is
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responsible for liver damage in humans. Kava has been used
traditionally for thousands of years.
Saw palmetto (Serenoa repens) is used by over 2 million men in
the United States for the treatment of benign prostatic hyperplasia
(BPH). The evidence suggests that saw palmetto provides mild-tomoderate improvement in urinary symptoms and flow measures in
some patients. Saw palmetto produces similar improvement in
urinary symptoms and flow compared to finasteride (Proscar),
a pharmaceutical drug used in BPH, and is associated with fewer
adverse treatment events.
• St. John's wort (Hypericum perforatum) is well known for its
antidepressant effects. The clinical efficacy of some standardized
St. John's wort standardized extracts in the treatment of mild and
moderate depression has been demonstrated in about 40 controlled
clinical trials(14), [but there remains considerable controversy because of many negative studies - Ed.]
• Echinacea preparations (from Echinacea purpurea and other
Echinacea species) may improve the body's natural immunity.
Echinacea is one of the most commonly used herbal products, but
controversy exists about its benefit in the prevention and treatment
of the common cold. A meta-analysis found that echinacea
supplements decreased the odds of developing the common cold
by 58% and the duration of a cold by 1.4 days(15).
With respect to the supplements above their benefits ranged from
mild to moderate and even in some instances that is debatable, while
many studies have been shown to be methodologically flawed..
Whereas the risk of liver damage with kava kava raises concern and
debate, and other agents have associated toxicity, yet persons still
gravitate to these supplements. The problem arises when these
supplements, some unregulated, are obtained by a consumer, often
self prescribed. Several herbal products are mislabelled carrying
undeclared additives (16), some addictive. Hence the addictive
nature fuels the continuous purchase of the product. Also several of
these supplements often, it is said, have to be used together to
increase effectiveness and reduce toxicity. There is an irony to those
seeking an alternative to he many pharmaceutical brands both over
the counter and prescription, as the costs are perceivably cheaper.
In one’s quest to attain an alternative more natural route that may
be at a lower cost initially, considering the continual consumption
of the product that may be necessitated the costs may be far more
than the conventional medicine.
However there is still confusion between herbal medicine and
herbal remedies and therein the problem lies. There are some herbal
alternatives being marketed as herbal supplements which are
classified as dietary supplements.(17). Unlike pharmaceutical drugs,
these can be marketed without undergoing testing to prove their
efficacy and safety. In addition, there may not be an associated
benefit to using the alternative herbal medicine but may appear to
be as one may not be riddled by the side effects of the
pharmaceuticals. There are also some instances where the very
alternative creates alternate side effects. For example:
cont’d
warfarin (Coumadin, a blood thinner), protease inhibitors for
HIV, birth control pills, certain asthma drugs, and many other
medications. In addition, St. John's wort should not be taken with
prescribed anti-depressant medication. The FDA has issued a
public health advisory concerning many of these interactions.
• Bleeding time may be altered with the use of garlic, ginkgo,
feverfew, and ginger, among others.
• Evening primrose (Oenothera biennis) may increase the risk
of seizures in patients taking drug known to lower seizure
threshold, such as anticonvulsants.
• Some herbal supplements, especially those imported from
Asian countries, may contain high levels of heavy metals,
including lead, mercury, and cadmium
Unfortunately, a recent study in the New England Journal of
Medicine indicated that nearly 70% of individuals taking herbal
medicines (the majority of which were well educated and had a
higher-than-average income) were reluctant to reveal their use of
alternative medicine to their doctors. Because herbal medicines
contain a combination of chemicals, each with a specific action,
many are capable of eliciting unwanted or unexpected results when
combined with conventional drugs. This can result in further
expense to the person as they spend to money trying to rectify the
problems associated with the herbal medicine superimposed with
their original complaint.
There is also the unique situation, particularly to the
Caribbean (18), of the so-called “Backyard medicine” which is
separate from purchasing herbal supplements in a local health store.
A classic example is within the Caribbean community, where there
is a tradition of using herbal remedies from the garden for
maintenance of health and wellbeing, treating everyday ailments or
even chronic conditions such as “pressure” or hypertension. Plants
such as Cure-for-all and cerasee are used to detoxify the body while
others such as young papaya, parsley and garlic are used to help
lower blood pressure. These alternatives are virtually free and have
been used for generations. This mode is generally preferred by the
older population (60+ years) as they prefer not to take several
tablets a day with no perceivable change. The use of these remedies
served as an empowerment strategy where the person gained
control over the treatment of their condition. Most of the time, this
was not revealed to their health care professional, and hence there
was the same risk of the problem, the original disease process,
being exacerbated and the subsequent costs being far more costly
than what it originally was. In recent times, primary health care
practitioners have taken this into account, acknowledged the
possible use of herbal remedies and learnt to address such cultural
practices of their patients.
to be continued next issue.
SUCCESS IS NOT THE KEY TO HAPPINESS.
HAPPINESS IS THE KEY TO SUCCESS. IF YOU
LOVE WHAT YOU ARE DOING, YOU WILL BE
SUCCESSFUL.
...Albert Schweitzer
• St. John's wort causes sensitivity to the sun's ultraviolet rays, and
may cause an allergic reaction, stomach upset, fatigue, and
restlessness. Clinical studies report that St. John's wort also
interferes with the effectiveness of many drugs, including
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LETTERS TO THE EDITOR
Pursuing Specialist Registration for All Family Physicians
The University of the West Indies has been training family physicians
in a 4 year DM residency program for more than 25 years now but
as it exists, the output is small with only 3 posts. By utilizing our
polyclinics as new training sites and the existing graduates as
associate lecturers, an expansion of this program would be
relatively straightforward and inexpensive. Meanwhile the Diploma
programme, an “in-service” programme, provides a realistic
intermediate step, which the University has proposed should be the
initial requirement for new graduates going into family medicine.
The biggest challenge would be to phase out the designation
of GP in time and in a way that is fair to those already practicing for
many years without postgraduate qualifications. With the capacity to
train larger numbers, a slow but smooth transition would be best
accomplished by simply requiring that all new MBBS graduates enter
supervised postgraduate training. Such a move should be coupled
with the introduction of mandatory periodic re-certification for all
family physicians. In this way, all will be afforded an opportunity to
continue practising while ensuring an acceptable standard of care for
our patients.
Dear Sir
With the advent of specialist registration and mandatory
continuing medical education, the next logical step for Barbados is
to do away with the old designation of general practitioner (GP)
and insist on postgraduate education for all family physicians. Apart
from the fact that most developed countries have taken a similar
stance, there are several compelling arguments for this approach.
Firstly, it has been well established since the Alma-Ata
Declaration of 1978 that robust primary health care is the most
cost-effective level of intervention. With our high burden of chronic
non-communicable diseases, it does not make sense that we have
our least-trained doctors managing these cases. On the contrary,
family physicians should be more skilled at treating and preventing
these lifestyle diseases than any other member of the healthcare team
and should be at the forefront of our battle with this pandemic.
Broad and dynamic, the specialty of family medicine is perhaps
the most challenging. Furthermore, in a small population such as
that of Barbados, that is already saturated with doctors, there is no
need to push new graduates straight into unsupervised practice. With
a very limited need for other specialists it follows that we should turn
our attention to improving the quality of our family physicians.
Dr. Joseph Herbert
Resident, DM Family Medicine
Concerns In Relation to the developing Epidemic of Obesity and Chronic-Non
Communicable Diseases Among Children in Barbados - What can we do?
stimulants, sometimes force feeding and other measures were often
administered and practised by parents and guardians in an effort to
get the child bigger and “to grow”.
With a right-about-turn towards CNCDs in childhood, early
detection and plotting of growth parameters and BMI have become
an absolute “must” in the consult for each child we see. This is likely
to reap significant rewards, especially when done with some
precision. The accuracy is facilitated by the first Barbados Health
Record booklet-in-use, which in addition to having growth charts
and BMI charts, devotes a section to guidelines for the revised
weaning diet and much more. Failing to adopt this recording
practice might indicate that the medical profession is skirting
one of the main issues which has been on the horizon for some time
and contributing in a negative way to the new and emerging challenge
of CNCDs for our children. Indeed, observations reflect that for a
significant percentage of well child visits, the parameters have not
been completed by a health care provider.
In addition to what has been demonstrated in the sphere of
academics, children on our island have now caught up with those of
the developed countries, namely in the area of the increasing prevaence of CNCDs. Health surveys in recent times (Gaskin et al,
2008, Fernandez et al, 2011) have documented figures in the vicinity
of around 20% obesity among randomly selected primary school and
adolescent populations. Yet another survey revealed that the habit of
virtually no energy-burning activity was being perpetuated from their
11th year onwards, especially in teenage girls. The predominance of
females leads by some distance in this respect. This development has
also been reported from other islands in the region.
Dear Sir:
In the day to day experience of my profession and specialty, it
has become abundantly clear that there is a need to address the increasingly prevalent new challenge - the development of chronic
diseases in childhood. Formerly, this subject was never associated
with the paediatric population, being more often than not a challenge
in the practice of adult medicine. More recent trends indicate that
the subtle signs are certainly present, and there is a dire need for
attention to the standard indicators among children who present
either for illness or “well child” visits. Practitioners operate in busy
practices on a daily basis. Within limited time constraints, there has
been the traditional tendency towards directing the main focus of
attention to a basic history, cursory examination for detection of
abnormal physical signs, followed by prescribing and treatment, in
the care of children and adolescents.
This emerging epidemic of the Chronic Non- Communicable
Diseases (CNCDs) in the paediatric population is right here on our
doorstep and it calls for a change in thrust during medical office
visits. The increasing epidemic is looming large. The entire
scenario has presented a completely new dimension, since CNCDs
have been on the rise on a global basis, and have been reaching an
alarming rate in recent years.
In former times, obesity, primary hypertension and diabetes
type 2 were unheard of and un-described among this age group.
The diagnosis of metabolic syndrome did not exist. It did not
appear necessary to evaluate a paediatric patient for any of these
conditions. The challenge was, more often than not, whether the
child weighed enough. Vitamins, for what they are worth, appetite
31
B A M P
2 0 1 1
L E T T E R S T O T H E E D I T O R . . . cont’d
Counselling at every opportunity must be adopted. The involvement
of the total team - physician, nutritionist, school, family unit and
sometimes the extended family unit, must all come into play.
Education of our peers, health care providers and those involved with
motivating students to exercise, at the level of both primary and
secondary schools and nursery levels is surely the way to go. A serious
look needs to be taken at the policies established by the Education
Ministry and school governance committees for mandatory allocation
of set proportions of time to be allocated for physical education and
activity programmes in the school setting, making the activity mandatory
until graduating from secondary school. A further step, with the challenge
increasing, would involve looking towards pharmacological therapy for
the obese, with one recommended choice being biguanide medication.
What when all else fails? Some proposed measures put forward as a
solution for dealing with extreme cases of childhood obesity include
recommendations that state intervention (e.g., child protection services)
may be warranted, as in the UK. State intervention is not desirable or
ethical for many obese children, and removal from the home does not
guarantee improved physical health. Surely we do not wish to resort
to such punitive measures for a resolution of the epidemic at hand
and significant health challenges!
An appeal is being made for our health care providers to assume
their full share of responsibility and to put a significant effort into the
prevention and detection of CNCDs. In the final analysis, the state
of our children’s health can make a significant impression on the
island’s wealth.
Using analysis and introspection there are some pertinent
observations and questions which pose food for thought and there is
evidence-based research and reports which have emerged from local
research. For instance:
- from as far back as in pregnancy, the weight gain and ultimate foetal
size can influence the weight of the infant at birth
- a direct relationship has been shown between birth weight and
development of CNCDs in later life; also the rate of weight gain in
the primary years exerts an influence
- a direct relationship between calorie intake in the first few years of
life and the prevalence of CNCDs in later life
What role has the time period of preparation for the common entrance
exam play in the potential to develop CNCDs? During this period
parents report that they “stopped their child’s participation or
significantly reduced time allowed for sporting activities because of a
fear of inability to attain a balance between academic and sporting
activity balance.”
Besides focusing on the physical complaint posed by the parent, how
many of us physicians focus directly on food intake versus energy
expenditure as we see our little and not-so-little patients for their
health visits?
Evidence from surveys on dietary intake and selection of food
choices strongly suggests that, in our island culture, we need to increase
physical activity through outdoor play and decrease intake of
sugar-sweetened beverages, especially the carbonated drinks and juices
purchased at retail outlets in Barbados, which are loaded with sugars.
Low fibre meals, large portions, predominance of carbohydrates
and high fat content in meals consumed are widely observed.
M. Anne St. John
Consultant Paediatrician
INSTRUCTIONS TO AUTHORS
References should be indicated in the text with an Arabic numeral in brackets, e.g. (1) or (6,7), numbered in order of appearance and listed at the end,
using the style of “Uniform Requirements” in the New England Journal of
Medicine and as referenced here: (New Engl J Med 1997; 336: 309-15).
They should give the names of up to four authors. If more than four, they
should give the first three followed by et al. The title should be followed by
the journal title (abbreviated as in Index Medicus), year of publication,
volume number, first and last pages. References to books should give the
names of authors (&/or editors), title, place of publication and publisher, and
year of publication.
Other examples, taken from the instructions in the Journal of the Royal
College of Physicians, are:
BAMP Bulletin is the journal of the Barbados Association of Medical
Practitioners (BAMP). It is now effectively in its 35th year, having replaced
the initial Newsletter of the Association, begun in 1976.
The Editor is assisted by members of an Editorial Committee, chaired
by the Public Relations Officer of BAMP Council, and comprising a cross
section of BAMP membership, from Professor Emeritus to medical resident.
There is also an Advisory Board of seven senior members of the profession
(See page 3) and since the beginning of 2011, with the publication of the
new Bulletin, submitted papers are peer reviewed, usually by members of
the Advisory Board or other local specialists in the relevant area. Expansion
of the Advisory Board and of our reviewers to include international experts
is planned.
Manuscripts should be clear, concise, accurate, and where appropriate,
evidence-based, but written, in the words of the Royal College of Physicians,
“with a style that retains the warmth, excitement and colour of clinical and
medical sciences”. Content may range from letters to the editor and clinical
case reports to short Commentary articles, clinical or epidemiological studies,
CME review articles or historical articles. Good items of medical humour
are accepted, and quality photographs or paintings may be submitted to adorn
the cover, which will have the new, dramatic masthead above a photograph
or painting. Historic photos, such as that of the General Hospital senior medical and nursing staff in 1938 in the issue July / August, 2011, are welcome.
Authors are asked to indicate with their submission any competing
interest, including any funding for a study. They are asked to submit in
Word, to edit their work carefully, and to provide full name and
qualifications, address (email address optional), a word count, a portrait
photograph, and an abstract of not more than 200 words.
1. Abbasi K, Smith R. No more free lunches. BMJ 2003;326:1155–6.
2. Hewitt P. Trust, assurance and safety – the regulation of health
professionals in the 21st century. London: Stationery Office, 2007.
www.officialdocuments.gov.uk/document/cm70/7013/7013.pdf
Accuracy of references is the responsibility of the author.
Photographs and illustrations should be submitted as separate attachments
and not embedded in the text.
Submission of an article implies that it represents original work or writing
and is not submitted elsewhere. However relevant articles of interest that
have been published elsewhere may be accepted if clearance is obtained from
the first journal and republication is stated, or may be abstracted for airing in
the BAMP Bulletin, with appropriate reference.
Articles, letters and all items should be submitted to BAMP Office
([email protected]) and to the Editor at [email protected]
32
Lifestyle-related diseases such as heart
disease, cancer, diabetes, hypertension,
stroke and obesity are spreading through
our region, and continue to create serious
social and economic challenges. We must
all seriously commit to doing our part in
promoting increased physical activity and
healthy eating to live longer, healthier lives.
Sagicor also supports the regional goal
that, by 2012, 80 percent of people with
non-communicable chronic diseases will
receive quality health care and have access
to preventative education.
HEALTH IS A STATE
OF COMPLETE
HARMONY
OF THE BODY,
MIND AND SPIRIT.
LIFE INSURANCE | GENERAL INSURANCE
ASSET MANAGEMENT | MORTGAGES
SINCE 1840
CARIBBEAN | LATIN AMERICA
UNITED KINGDOM
UNITED STATES OF AMERICA
ED
RAT
“A -” (EXCELLENT)
BY
00
00

Bulletin - November 2011 - Barbados Association of Medical

Transcription

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