The New Nation - Internet Edition

Fistula: Awareness is the best way to escape

Arifa As Alam

Asma Begum was married off when she was only 14. She became pregnant in no time. Despite all the odds, Asma began dreaming of her unborn child. But that was not to be.

During delivery, Asma faced serious complications. Her life was at stake. So, the doctor preferred cesarian section to save her life. Though she survived, her vaginal passage, urinary bladder and rectum merged together. As a result, Asma lost control over urination and defecation. Urine and stool used to flow continuously. And her husband abandoned her to make the matter even worse.

Prof Sayeba Akter of Bangabandhu Medical University says Asma has developed fistula. Due to malnutrition, early marriage and prolonged labour, her baby got stuck in her vaginal passage, with the bone of urinary bladder and rectum in such a way that her doctors were compelled to resort to cesarian section. As a result, her vaginal passage, urinary bladder and rectum got merged making her a fistula patient.

Prof Sayeba says if the delivery is obstructed due to any other reason other than contraction of the uterus or if the labour lasts more than 12 hours, the baby's head can be trapped in the tip of uterus. At that time, the urinary bladder and rectum remain under pressure due to the baby's position. And due to the pressure, blood circulation in these limbs is hindered and the rot begins there. Within a few days, there develops a hole and this problem is called delivery-related fistula.

She further says, "If there is any abnormal connection between the urinary bladder and vaginal passage, it is called Vesicovaginal Fistula (VVF), while the abnormal connection between rectum and vaginal passage is called Rectovaginal Fistula (RVF)." According to the UNFPA, there are now about 2 million under-18 mothers in the developing world. Being isolated and insulted, these young women are leading a dreadful life -- both physically and mentally. The UNFPA says the vaginas of young girls are small compared to the shape of an unborn baby. On many occasions, babies are dangerously positioned inside. As a result, during delivery, holes are found in vaginal passage and urinary bladder or rectum or in both places.

Currently, there are many like Asma who are affected by various pre- and postdelivery-related diseases. Among the diseases, childbirth-related fistula has taken a dangerous turn in Bangladesh and other developing countries. According to UNICEF, the outbreak of the disease is widespread in the poor countries of Asia and Arab and Sub-Saharan Africa.

A UNFPA-assisted survey conducted in Bangladesh in 2003 shows the number of women affected by fistula is 1.69 in 1000. According to this calculation, there are more than 70,000 fistula-affected women in the country. Most of these women live in poor, rural and remote areas where acceptable maternity care is not available. According to UNICEF, the mortality risk of l5-year-old pregnant girls is five times higher than those of 20-year-old women and above. And the risk of being affected by fistula is very high among under-aged pregnant girls. Engender Health Bangladesh, an international NGO, is working with assistance from the UNFPA for eradicating delivery-related fistula. SM Shahidullah, the person responsible for implementing the fistula programme, says women get affected mainly due to delayed delivery, obstructed delivery, lack of education, malnutrition, early marriage, pregnancy at early age, lack of emergency maternity care, absence of skilled midwives, lack of knowledge about prolonged or obstructed labour and lack of training among health personnel. Besides, one can get affected as a result of operation during delayed or obstructed delivery. He also says generally village women are affected by fistula. The low standard of living, early marriage, constant pressure to go for having children, ignorance about pregnancy, negligence to healthcare before and after delivery, conservativeness, confidence in conventional treatment, reluctance in delivery in hospital, unwillingness to be treated by male doctors, reluctance to transfer pregnant women to hospital, transportation problem, lack of money etc may cause this embarrassing disease.

Prof Sayeba says many people do not talk to others about the disease due to ignorance or out of shyness. Then again many people even do not know if there is any treatment for it. As a result, they continue to suffer from fistula though it is curable. According to the UNFPA, 90 percent of the patients get cured through operation. It costs about US$ 300 for the treatment and care afterwards. After five surgeries, Asma is now fully well and she is now a mother of a lovely child born through operation after her second marriage.

SM Shahidullah says National Fistula Centre was set up in 2003 in the Dhaka Medical College Hospital. At non-government level, fistula treatment and care is available at Memorial Christian Hospital, Cox's Bazar, Mirzapur Kumudini Hospital and Lamb Hospital, Dinajpur.

Statistics from the National Fistula Centre shows the number of patients visiting the centre is gradually increasing. But the number of beds has not increased. There are only 13 beds in the Dhaka Medical College Hospital for fistula patients, which is somewhat inadequate. Allocation needs to be increased. Besides, there is a need for more centres for treatment and care. To save women from the severity of the disease, service will have to be made available for the patients, says SM Shahidullah. New arrivals are not free from the dreadfulness of the disease. Due to obstructed delivery, there may be problems in children's bones. Even they may die. But subject to a little bit of awareness, one can escape from this disease. There is a need for ensuring emergency maternity care during pregnancy.

He also says, "The expectant mothers need to be taken to hospitals or clinic for delivery. If not possible, there will have to be arrangement of a skilled midwife at home. Emergency transport has to be arranged. There should be separate savings for any emergency during delivery."

Prof Sayeba says being aware is more important than to be affected by any disease. The main objective of the care during pregnancy is to detect probable complications and be prepared accordingly. If care during pregnancy can be ensured, the number of fistula-affected women will reduce significantly. And to do that, awareness among women is a must.

She also says there are some misgivings about the disease. Many think if anyone is affected by fistula she will not be able to be mother again. Many husbands believe normal sexual relationship is destroyed due to it. There is no possibility of either of it if treated in time.

The important thing is only mass awareness can address all the problems relating to fistula.

Care for children and adolescents living with diabetes

Amit Dwivedi

Diabetes is a deadly disease, and each year, almost 4 million people die from diabetes-related causes. Children, particularly in countries where there is limited access to diabetes care and supplies, die young", according to International Diabetes Federation (IDF) which is an umbrella organization of over 200 member associations in more than 160 countries. IDF leads World Diabetes Day (www.worlddiabetesday.org) which falls on 14th November. The campaign is focusing its efforts on raising awareness of diabetes in children and adolescents.

Diabetes is one of the most common chronic diseases to affect children. Every day more than 200 children are diagnosed with type 1 diabetes, requiring them to take multiple daily insulin shots and monitor the glucose levels in their blood. It is increasing at a rate of 3% each year among children and rising even faster in pre-school children at a rate of 5% per year. Currently, over 500,000 children under the age of 15 live with diabetes, according to IDF.

Since diabetes often requires life-long monitoring, care and treatment, is hospital-based approach better than home-based care approaches or a mix of these two approaches for effectively responding to care needs of those with diabetes?

Dr Sonia Kakar, a New Delhi based doctor, said: "hospital-based approach should be for the management of acute and/or chronic complications arising out of diabetes. But as 99% of diabetes care is self-care, empowering people with right information can make home-based care approach more feasible and economical."

She also felt that, "adolescents often have the motor and cognitive skills to perform all diabetes-related tasks and determine insulin doses based on blood glucose levels and food intake. Thus, they must be supervised in their diabetes tasks and allowed gradual independence with the understanding that the independence will be continued only if they adhere to the diabetes regimen and succeed in maintaining reasonable metabolic control."

"During mid-adolescence, the family and healthcare team should stress upon the teenagers the importance of checking blood glucose levels prior to driving a car to avoid hypoglycemia while driving" stressed Dr Kakar.

Managing diabetes in children and adolescents becomes more effective when the entire family gets involved. Families should be encouraged to share their concerns with physicians, diabetes educators, dieticians, and other healthcare providers to get help in the day-to-day management of diabetes. Extended family members, teachers, school nurses, counsellors, coaches, day-care providers, and other resources in the community can provide information, support, and guidance regarding skills to cope with the disease. They may also act as resource persons for health education, financial services, social services, mental health counselling, transportation, and home visits.

"Diabetes is stressful for both - the child as well as his/ her family. Parents should be alert for signs of depression, eating disorders or an unexplained loss of weight and seek appropriate medical help. While all parents should talk to their children about avoiding tobacco, alcohol, and other drugs, this is particularly important for parents of children with diabetes. Smoking and diabetes both increase the risk of cardiovascular diseases and those people with diabetes who are smokers are at an increased risk of heart/ circulatory problems. Hence parents/ family members of children/ adolescents living with diabetes should refrain from tobacco use in order to avoid sending wrong signals to their wards" recommends Dr Anoop Misra, Director and Head, Department of Diabetes and Metabolic Diseases, Fortis Hospitals New Delhi and Noida.

Depending on their age and level of maturity, children living with diabetes should be encouraged to take care of themselves. Most school-age children can recognize symptoms of hypoglycemia and if they are over 12 years old they may be able to take insulin injections of correct dosage by themselves. They can also be involved in planning their diet chart.

Treatment of diabetes in adolescents is complex and should only be handled by experienced physicians. Also, such patients should be looked after by a team consisting of diabetologist, nutritionist, diabetes educator, and psychologist.

Educating people with diabetes about diet, exercise and drugs is the most important part of the initial management of the disease and should be accomplished in several sessions. Insulin management should be discussed and demonstrated to children and parents, so that they can take insulin injections themselves. Parents, along with their children, should be made aware about healthy eating habits, physical exercise, and dosage management of drugs/ insulin.

IDF is bringing together key opinion leaders to push for action to secure care for the thousands of children with diabetes in developing countries without access to care at a meeting in London on October 25. The meeting, Access to Essential Diabetes Medicines for Children in the Developing World will focus on ways to help keep more children alive and healthy with diabetes. Ministries of Health from various developing countries, leaders from the pharmaceutical industry, philanthropic foundations, leading supply-chain management firms, diabetes associations, as well as professional societies in paediatrics and diabetes education have been invited to the meeting.

Close to 75,000 children in low-income and lower-middle income countries are living with diabetes in desperate circumstances. These children need life-saving insulin to survive. Even more children are in need of the monitoring equipment, test strips and education required to manage their diabetes and avoid the life-threatening complications associated with diabetes.

"We are bringing together the people and the organizations that can provide not only the interim humanitarian response to save lives but can lay the groundwork for sustainable solutions that will benefit all children with diabetes," said Dr Martin Silink, President of the International Diabetes Federation (IDF).

Thankuni is effective cure for skin diseases

Jamayet Ali

Thankuni is a very popular small herbaceous plant belonging to the family Umbelliferae, and comprising about 70 species which are found in wet places in temperate and tropical regions, more especially of the Southern hemisphere. In Bangladesh it is found in damp places, by the side of the pond, ditches, streams and also by the side of the zigzag paths in rural areas. Its botanical name is Hydrocotyle asiatica. The leaves are sometimes made into a soup, which, however, probably serves more as a medicine than as a food. It is also known as Tholkuri.

Medicinal Properties: The plant is acrid, bitter, sweetish, digestible, laxative, cooling tonic, alterative, alexiteric, antipyretic; improves appetite, voice, memory; cures leucoderma, anaemia, urinary discharges, diseases of the bold, bronchitis, inflammations, fevers, "kapha", biliousness, enlargements of the spleen, thirst, asthma, smallpox; used in insanity (Ayurveda). The plant has a bitter, bad taste; soporific, sedative to the nerves, tonic cardiotonic, bechic, stomachic, carminative, diuretic; clears the voice and the brain; cures hiccough, asthma, bronchitis, scalding of urine, headache; improves appetite (Yunani).

The plant is considered a beautiful alterative and tonic in diseases, of the skin, nerves and blood. In some areas, the people are in the habit of taking the powdered dried leaves with milk for improving their memory, and as an alterative tonic. The leaves are said to be useful in syphilitic skin diseases, both externally and internally; and on the Malabar coast, the plant is one of the remedies for leprosy. Dr. A. Hunter, after trying it in the Madras Leper Hospital, come to the conclusion that it had no claim to consideration as a specific in leprosy, but found it most useful in ameliorating the symptoms and improving the general health.

In Bombay, it is popular remedy for the slight dysenteric derangements of the bowels to which children are subject three or four leaves are give with cumin or sugar, and the pounded leaves are applied to the navel. In the Konkan, one or two leaves are given every morning to cure sluttering; and the juice is applied (generally as a lep with Cadamba bark, ghi, and black cumin) to skin cruptions supposed to arise from heat of blood. In Java, according to Horsfield, the leaves are considered diuretic. In Ceylon, the leaves are taken as a tonic and blood purifier; also for indigestion, nervousness and dysentery. In Indo China, the plant is considered diuretic. It is used internally as an alterative tonic, and externally as a stimulant. The entire plant is used by vaidyans in derangement of the three humours. The leaves are used as diuretic and are said to be beneficial in skin diseases, especially in leprosy. For leprosy it is given in the form of powder, decoction, or syrup. A syrup of the leaves was administered in two cases of chronic psoriasis. There was some improvement noticed in the patches after its administration for a few days. The plant in combination with other drugs, is recommended snake-bite (Rasaratnakra); but, no part of it is an antidote to snake-venom (Indian Medicinal Plant, Kirt. & B.D. Basu, II, 1194, 1195).

Medicine: The part of the plant generally employed are the leaves, deprived of their petioles, dried by exposure to the air in the shade, and ground to a powder. It appears that if dried in the sun, or by any method of artificial heat, the leaves loss a great part of their medicinal properties, owing to the volatalisation of the oil which is their active principle.

The powder thus carefully prepared ought to be kept in well stoppered bottles to prevent the access of moisture. When fresh, the leaves have scarcely any smell, but emit a peculiar faint, aromatic odour when crushed between the fingers. They have a harsh, bitter and disagreeable taste, which however, becomes scarcely perceptible after the leaves have been well dried.

Applications in medicine: The principal value of the drug appears from its physiological action to be as a stimulant to the cutaneous circulation in skin diseases, and for this purpose it will be found to have been chiefly employed. Though it appears to have no specific effect in leprosy, nor in syphilis, this can be little doubt by its action in stimulating circulation it is of value in this affections. Dr. Shortt speaks of the drug in high terms, and considers it to have a powerful action in all leprous affections. But letter writers agree that its effects are most marked in the preliminary anaesthetic stages of the disease. Drs. Lolliot, Cazenove, and Bertin find it of little value in advanced cases of tubercular leprosy, but extol its virtues in the treatment of chronic and obstinate eczema, the letter remarking: "The eczemas treated by me with the preparations of Hydrocotyle were of the most rebellious type, viz., localized eczemas; nevertheless cures were effected in every case and that within a very brief space of time."

It has also been prescribed with excellent result in cases of secondary and tertiary syphilis accompanied gummatous infiltration and ulceration; in chronic callous ulcers; as a stimulant to healthy mucous secration; in fantile diarroea and azoena; in case of scrofulous ulceration, enlargement of glands and abscess; and in chronic rheumatism. It has also been employed with success as a diuretic in several diseases, and as an emenagogue in cases of amenorrhoea. In all cases in which a constitutional or general diseases is accompanied by a local lesion, the drug ought to be not only administered internally, but also applied locally as a power, poultice or ointment. Numerous descriptions of cases so treated by practitioners in many parts of the world have appeared of late years, with the result that the use of the plant is becoming daily more wide spread and the belief in its therapeutic value more universal. Under these circumstances it would certainly seem advisable to give the whole plant a careful trial, as recommended by Boileau, and more recently again strongly advised by Daruty, as it is quite possible that much of the disrepute into which it has fallen in India may be the result of the Pharmacopoeia recognizing only the least active part, viz. the leaves.

Special opinions: "Is largely used in brain affections and insanity. A decoction of the leaves is evaporated with butter and the resulting preparation is then given internally" (Surgeon-Major Robb, Civil Surgeon, Ahmedabad). "This drug deserves attention. Its efficacy in these cases is well marked" (U.C. Dutt, Civil Medical Officer, Serampore).

"A very useful alterative in constitutional syphilitic ulcers and skin disease. Dose, 5 to 10 grains of powdered leaves. Externally stimulant" (Thomas Ward, Apothecary, Madanapalle, Madras). (Much used in the hospital, similar to Calotropis; and always combined with it. A valuable alterative tonic used in all cases of leprosy and obstinate forms of skin diseases. The following formula is employed here. Pulvis Calotropis, grains iii, Puvis Hydrocotyle grains x., twice a day. At times combined with iron preparations" (J.G. Ashwarth, Apothecary, Kumbakonom, Madras) (Dictionary of the Economic Products Of India, Hydrocotyle, 312,313).

An infusion of the plant is used in and Madagascar in the treatment of leprosy and is known to ameliorate the symptoms of the disease and to improve the general health of the patient. The leaves are commonly employed, but the use of the whole plant is recommended. The usual dose for oral administration is 5-10 grains of the plant powder thrice daily (Wealth of India, Raw materials, Hydrocotyle, 117)