In an era of unlimited information, it can be difficult to separate medical fact from fiction, with a number of different sources presenting conflicting accounts of the causes and cures for the health issues afflicting the Sri Lankan population. In light of this, the Chair Professor of Medicine of the University of Colombo and Hon. Consultant Physician at the National Hospital of Sri Lanka Saroj Jayasinghe forms a clearer picture with regard to some of the pertinent issues affecting the health of the Sri Lankan population.
Q: Why has the incidence of non-communicable diseases (NCDs) such as diabetes, heart disease and cancer been increasing in Sri Lanka? Are there some underlying lifestyle factors that have led to an increase in each of these diseases respectively?
A: The incidence is increasing due to a number of factors or determinants. Firstly, our lifestyles have changed. We are more sedentary because we are seated most of the time in front of a computer or desk or in a car, unlike our previous generations who had to walk to work, did more physical work and stayed seated less in one place. We are also eating more refined food than before. This includes processed meats, sweet beverages, starch-based food, sweets such as chocolates. The volume of what we eat has also increased and more and more calories are now been consumed by humans than ever before. To add to this the present generations are consuming alcohol and tobacco which are major contributors to NCDs such as chronic liver disease and chronic bronchitis, lung cancer and coronary artery disease.
Thirdly, there is the problem of stress. This is defined in many ways. Whichever definition we use for stress, the demands or needs far exceed what we have, and as a result, there is a constant load of stress among many categories of people all over the world. This leads to increased secretion of stress-related hormones such as cortisone by the adrenal glands that sit on top of the kidneys, and activation of a part of our nervous system called the autonomic nervous system. The latter functions ‘outside’ the conscious experiences and is responsible for the heart rate, the breathing rate, movements of the gut and sweating etc. Finally, people are living longer and therefore they are more liable to get these diseases as they age.
Some would call the first three behaviours described in the previous paragraph as lifestyle factors as ‘proximate’ determinants of NCDs. By the term proximate determinants, we mean those which are proximate or immediate or very close to the disease itself, both in the dimension of time, as well as in space. Lifestyle is a proximate determinant because it is the immediate ‘cause’ or determinant that we can observe ‘causing’ NCD. To give a simile, a person who falls while running does so because he tripped on an up-turned pavement slab on his path. The up-turned slab is the proximate or immediate cause for his bruising fall, and the events prior to that (he was running because a negligent homeowner had not tied the domestic dog, and those doing road works had not paved the pavement properly) are more distal.
The distal determinants are described as ‘causes of the cause’, i.e. the more distal causes that lead to the proximate ones, and known technically as ‘social determinants of health’. They are the events that precede the proximate cause. In the case of NCDs, the lifestyles are determined to a large extent by preceding or distal factors. These include the policies on advertisements (which allows for promotions targeting children), information on food labels (e.g. the requirements on what is to be stated in what language), pricing (e.g. tax on sweets based on sugar content) or restrictions in sales (e.g. limiting the sale of tobacco to adults).
Q: What are some misconceptions the public has about these NCDs? What are some changes in beliefs and behaviours we can make in order to prevent these diseases from occurring?
A: I feel it is very difficult for misconceptions to change in the current environment though we should continue to be optimistic. For example, the fact that sugar is bad for health (irrespective of whether one has diabetes or not) is an important bit of information that the general public should be aware of. However, this bit of knowledge has to counter all the advertisements that promote chocolates in billboards, in TV advertisements and in supermarkets. The misconception that is promoted by the latter that sugar is ‘good’ will, of course, win the child over! This is why the traffic light sign on beverages to indicate sugar content should be commended. The Ministry of Health has also proposed an extra tax on sweetened food which should also be supported. Another example is the common misconception that alcohol has a safe limit and moderate quantities are beneficial to health. This myth has entered our belief system, carefully engineered by the industry and has continued for several decades, despite evidence to the contrary (i.e. even a single glass of alcohol is NOT good for your health).
Q: On the topic of lifestyle factors, concerns have been raised about the quality of the food consumed by the Sri Lankan population. Do Sri Lankans face a health problem with regard to the quality or type of food available to us?
A: Sure we do! We do not have the resources to test foods regularly and effectively. As a result, sub-standard food enters the market from overseas as well from within the country. This could be due to food being spoilt due to improper storage. It could be due to contamination with weedicides or pesticides, used in an unsafe manner. For example, most vegetables are highly contaminated by pesticides and weedicides. Some of the pesticides get absorbed and concentrated in yams and grains. There is recent research evidence from the Faculty of Medicine, University of Colombo, that some of the rice samples in the market have high levels of cadmium. This highlights the importance of having a central laboratory that will have the capacity to analyse food for contaminants on a regular basis to ensure the safety of our people.
Q: Continuing on the topic of nutrition, there has been a growing trend in Sri Lanka of taking over the counter vitamin supplements for their perceived health benefits. What does the evidence suggest about the efficacy of taking vitamin supplements? Are such methods of improving one’s health, grounded on a misconception about nutrition or do they have their place?
A: The rise and fall of supplements! Mostly vitamins are fads, promoted as healthy alternatives by the industry, the pharmacies and the medical profession. These are global markets valued at billions of dollars. We have seen many vitamins becoming famous for all kinds of ailments, only to fall into disrepute a few years later. Every time, the science looked convincing enough to ensure that these are prescribed. A current example is the explosion of interest in vitamin D. There are so many benefits of vitamin D that it has become the wonder molecule of the 21st century. Almost all diseases are linked to its deficiency, from autoimmune diseases to diabetes to infections. These are probably partly true there are health benefits of a normal level of vitamin D, compared to a deficient state. However, we need to scrape away the hype about it being considered the wonder compound rediscovered to benefit humanities ills from suicides to Alzheimer’s!
Q: Some people resort to traditional ayurvedic methods, to deal with NCDs. How must we approach this? Should there be regulatory bodies monitoring the efficacy and safety of such methods? How do we balance sound health policy with the rights of individuals to choose how they would like to be treated?
A: This is a very sensitive area and I shall tread very carefully. There are numerous research studies showing the benefits of traditional preparations in the control of certain chronic diseases. For example, the benefits of cinnamon in reducing blood glucose are well known. Karawila the bitter fruit has the ability to lower blood glucose levels (and both these studies were done in the Faculty of Medicine, University of Colombo). The problem we face is when these are recommended as drugs to be taken regularly over a long period. For example, should a person drink a glass of Karawila every day for 10 years? How safe is this? What is the evidence that it is safe? The answers to such questions are not well known. The other point is that even now most modern medical (i.e. western or allopathic medicine) practices have not been proven. Efficacy of what we prescribe is largely based on observations and studies that have been done with less scientific rigour.
Q: Which diseases are more economically vulnerable people more prone to in Sri Lanka? What can be done to combat this?
A: The poorer one gets the higher chances to fall ill with acute infections, parasitic infestations and is more vulnerable to injuries (from accidents or violence). One can understand this because the poorer people live in more deprived environments and lack adequate clean water etc. The more interesting fact is that studies in several countries have shown that the poorer groups have higher rates of non-communicable diseases too. In Sri Lanka disorders such as diabetes and obesity are seen more in the affluent, though this pattern is shifting. We are probably in the transition from a pattern where NCDs are diseases of the affluent, moving towards a situation where they are diseases of the poor.
In addition to the higher rates of illness, the poorer groups die younger and are ill for longer durations of their lives. Illness has a devastating effect on their lives because of the direct and indirect economic impacts. What we mean by direct impacts are the costs incurred due to the illness itself (e.g. costs of medicines, travel to clinics etc.). Our public sector health care system (the envy of many other countries) cushions this impact by providing almost all its services at no charge for the user. In other words, the ‘out-of-pocket’ expenses are minimal. However, there are indirect costs that have a severe effect on the household. For example, when a breadwinner falls ill, the income levels plummet. To cope with this, they borrow at exorbitant interest rates (so-called ‘ginipoli’) or sacrifice their children’s education and get them to the labour force or reduce consumption. The social services of the government do not give adequate support, and households rely on informal mechanisms where family members and friends support each other. Thus, illness has the potential to spiral households into deepening poverty. NCDs are chronic diseases and therefore the costs incurred are cumulative and long-term. As a result, they are known to lead to spiralling poverty and therefore known as a ‘medical poverty trap’. This is why it is very important to forge stronger links between the health sector and social services. Already there are discussions on having a cadre of medical social workers to facilitate this collaboration between the two ministries.
Q: There has been a high incidence of seasonal diseases, such as influenza amongst the population recently. What can be done, institutionally and individually, to combat the impact of seasonal diseases in Sri Lanka?
A: Influenza is what we call a pandemic, which means it spreads across countries and continents, due to increased travel and tourist traffic. As a country, we will, therefore, find it difficult to prevent the disease from entering Sri Lanka. We cannot detect all those infected at airports because the person may carry the virus and yet have no symptoms (i.e. during the incubation period of the illness). Once a person having the virus enters the country, it will spread very fast among those not having adequate immunity. An infected person can spread the virus even up to 3 to 4 days after the onset of feeling ill. The spread is mainly through tiny droplets of secretions we spray when we cough, sneeze or talk. The spray can go to about 6 feet! Another person gets the infection when these droplets land on the nose or mouth or is breathed into the lungs.
Confined spaces such as offices or classrooms or travelling in a coach or bus or train are ideal situations to spread such epidemics. Recently we encountered about 10 persons who developed influenza almost at the same time, a few days after attending a party of a mutual friend. We see large groups of students in a class affected at the same time and so on. Some of us catch the infection in a more isolated fashion, which is termed as ‘sporadic'. These are persons who seem to develop without anyone known to have the illness. This is either because the infected ‘donor’ of the virus was asymptomatic or the exposure might have been in a relatively isolated place (e.g. near a bus stand).
Luckily for us, there is a vaccine against the virus. New vaccines are required every year because the virus changes its outer proteins ever so often (which is a clever way to mislead our immune system). Therefore, as an institution, the best option is to get the workers vaccinated every year using the most reliable and latest vaccine. If a person develops the flu, (s)he should be strongly advised to stay at home. Coming to work despite having a virus infection is not a brave thing to do! You are infecting many more with the infection and the institution will ultimately be the loser! Here are a few more tips: covering your nose and mouth with a handkerchief when sneezing will reduce the chances of you spreading the illness; avoid touching your nose because the virus could also be lodged in your hands; most masks we have in the market are too porous and allows the virus to spread.
