The Creative Space

One day if I get the platform, this is an address I’ll love to give to the Ghanaian public. The topic will be on the issue of Chronic Diseases.
It’ll probably be in the evening and I’ll probably start like this…

Good evening, ladies and gentleman. Thanks for tuning in. Tonight, I want to talk to you about the issue of Chronic Diseases.
Everyone knows what a disease is and what it entails. It makes you sick and forces you to seek treatment. Some of you go to see a doctor. Others opt to see a traditional healer or herbalist. A few may do the unthinkable and just hope the disease goes away by itself. Whatever the measure taken, the hope is that the doctor, traditional healer, herbalist or time heals the body of the disease and brings back normalcy and good health. That is the general expectation.
However, what if the disease is such that no matter what the doctor or herbalist does, it does not go away or keeps coming back? There is a chance that the condition is not being treated well. However, there is also the possibility the disease is chronic.
Chronic diseases are long-term medical conditions that are generally progressive or persistent. They last longer than three months. Examples of chronic diseases are high blood pressure, diabetes, end-stage kidney disease, asthma, hepatitis C and cancer.

It used to be thought that the most important health issue in sub-Saharan Africa (SSA) was that of the infectious disease e.g. malaria, tuberculosis, cholera. Infectious diseases are still a major health risk in SSA but I contend that a few chronic conditions also are exacting a heavy toll on the populations in the region. I further seek to explain why the mentality of the population might affect how these chronic diseases are managed.

Of the examples on chronic diseases stated above, the two most common in Ghana seem to be high blood pressure (HTN) and diabetes.
In 2004, a study of the Greater Accra area found an urban prevalence of HTN to be 32.9% and a rural prevalence of HTN to be 24.1%. Similar studies in the Ashanti Region yielded prevalences of 33.4% and 27% respectively. A review of about seven studies by Addo has the rural prevalence at about 19% and the urban at about 55%
Diabetes on the other hand has a prevalence of about 6 – 9%, that is over 2 million people.
The mean age of diagnosis for both diabetes and high blood pressure seems to be in the mid-thirties.

Now both high blood pressure and diabetes can lead to very serious healthcare problems down the line if not managed well.
High blood pressure can lead to stroke, congestive heart failure and to loss of kidney function and even death.
Diabetes can lead to loss of limbs, blindness, loss of kidney function and death.

So it is of utmost importance for these diseases to be managed well. That is where the problem of the mentality comes in.
If a disease is always seen as a condition that can be treated away (acute), then getting patients to accept the fact that a disease can be chronic presents a problem.
Patients may not believe the diagnosis and seek a second opinion from another physician or traditional healer of even worse, do nothing about it. The fact that some diseases cannot be cured can be a bitter pill to swallow.

Then is what I call the “The Falsehood of Eternal Youth and Health”. Excuses like “I’m too young to have high blood pressure or too active to have heart disease” are common. Well, youth passes, even if slowly and good health is not always assured. Besides black people seem to have a propensity for certain ailments, one of them being high blood pressure.

The other issue is that chronic diseases demand a much higher level of patient involvement in managing the disease. Insulin must be injected, tablets taken daily for that high blood pressure, diets, exercise….it gets overwhelming and the onus is totally on the patient. Further, managing chronic diseases can be a financial as well as time drain. Consider having to undergo hemodialysis three times a week or the cost of medications to manage high blood pressure.
It is not at all surprising that faced with these prospects, some patients seek another way out – a cure from, say, a traditional healer or herbalist or just denial. In our Ghanaian culture, the rush to attribute a chronic ailment to a supernatural cause is ever present. That unfortunately leads down a path of figuring out the supernatural cause instead of treating the disease.

The Swiss psychiatrist, Elisabeth Kübler-Ross describes in her 1989 book, On Death and Dying, five stages that patients go through when faced with the diagnosis of severe illness. They are Denial, Anger, Bargaining, Depression and Acceptance. One is supposed to move from one stage to the next and finally end up accepting the diagnosis. It is in the acceptance of the diagnosis that propels a patient to deal and live with it. If one never gets to the acceptance stage, the results are the early end-stage effects of a disease.

This can be devastating if the patient is young, say, in their thirties.
If diseases like diabetes and high blood pressure, diagnosed when one is thirty are mismanaged or neglected, then by the time one is in his forties, the end effects of these diseases are apparent and lead to early morbidity and mortality.
These diseases need to be taken seriously and managed well, the minute a diagnosis is made, irrespective of the age.

The great thing is that, with all the advances in modern medicine, chronic diseases can be so managed as to ensure a long life. It however takes an active, very active participation of the patient.
Diabetes and high blood pressure are not the only chronic diseases. Like I mentioned earlier, I used them since they are the most common. There are of course people dealing with diseases like HIV, Parkinson’s, cancer, arthritis, asthma, kidney failure and congestive heart disease. Whatever the disease is, the same principle applies – acceptance.

So to summarize, not all diseases are acute e.g. malaria, and can be treated away. There are the class of diseases that persist and are chronic. Recognizing them for their severity and accepting them as manageable conditions si the first step and avoiding the late term effects of these diseases.

Thank you for listening and take good care of yourselves. You deserve that. Have a good night.

“Somewhere, something incredible is waiting to be known.” – Dr. Carl Sagan

In August of 1810, the English writer, Frances Burney, then living in Paris with her husband, General Alexandre D’Arblay and son, Alexander, developed pain in her right breast. She saw several French doctors. Fearing she may have breast cancer, a right mastectomy was ultimately recommended. The surgery was scheduled for September 30, 1811. In a period where surgery was done without anesthesia, she was given only a 2 hour notice. This was so she wouldn’t be frightened off. The surgery was attended by “7 men in black, Dr. Larrey, M. Dubois, Dr. Moreau, Dr. Aumont, Dr. Ribe, & a pupil of Dr. Larrey, & another of M. Dubois”. She was given some wine cordial after which she lay on the mattress designated as the operating surface. Her face was then covered with a transparent handkerchief. Below is part of her account of what happened:

“When the dreadful steel was plunged into the breast—cutting through veins—arteries—flesh—nerves—I needed no injunctions not to restrain my cries. I began a scream that lasted unintermittingly during the whole time of the incision—& I almost marvel that it rings not in my Ears still! So excruciating was the agony!”

Frances Burney survived the the mastectomy and lived another 29 years, dying at the age of 87. After the operation, she couldn’t think or speak of it for several months, had terrible headaches but had the courage to write an account of it to her sister.

Surgery before the discovery of anesthesia was so barbaric, some surgeons got drunk together with the patient for the ordeal. Surgeons were known to enter the theater with a bottle of wine in each hand – one for the patient and one for the surgeon. John Hunter, an early Scottish surgeon described surgery as ‘a humiliating spectacle of the futility of science’ and the surgeon as ‘a savage armed with a knife’! Techniques that were used to make it bearable for the patients included alcohol, opium, knocking the patient out with a blow to his jaw, rubbing them with stinging nettles and hypnosis. Patients would vomit and aspirate, blood loss was massive and the screams were haunting.
Now surgery is a painless, safe affair thanks to all the advances in anesthesiology, surgery and pharmacology.

Medicine and surgery have come really far from the days of Hippocrates. Matter of fact, they have even come father since a hundred years ago! Beliefs have changed and practices improved due to research. Whole diseases like the small pox have been eradicated even if we have replacements like HIV.

Talking about beliefs, the ancient Greeks, based on the teachings of Plato and Hippocrates, believed a woman’s womb was a separate creature with a mind of it’s own. When a woman did not bear children or abstained from sex, her uterus, hungry for children, could dislodge and float freely about her body causing shortness of air, seizures and mania. Women were advised to marry young and have a ton of kids. For a womb that had already broken free, doctors would “fumigate” the patient’s head with sulfur and pitch while simultaneously rubbing scented oils between her thighs. Why? The womb would flee from the bad smells and move back into its rightful place!

Or take the practice of bloodletting. The practice was common in ancient Egypt and got carried over to the Greeks, with Hippocrates and Galen being huge proponents. It was believed then that the human body contained the four “humors” – blood, phlegm, black bile, yellow bile – each centered in a particular organ—brain, lung, spleen, and gall bladder – respectively. Disease was thought to be from over-abundance of the humor blood so “letting” blood out of the body, brought the humors back in balance and healed the sick. Menstruation was seen as the body’s natural way of bloodletting to balance out the humors.
Now there are conditions like polycythemia vera, where the body produces too many red blood cells. A treatment option is bloodletting (Phlebotomy) and that is done even today. However bloodletting then was done for any and all ailments!
Bloodletting was common practice till the 18th century in Europe and the 19th in the US. As late as 1942, there were medical textbooks with bloodletting as a therapeutic procedure for all sorts of conditions. Dr Benjamin Rush, one of the signatories of the Declaration of Independence, was a fierce proponent of the practice.
The most famous victim of bloodletting in the US is probably the first president, Gen. George Washington. He had been sick and unable to swallow from a severe throat infection for a few days. On December 14, 1799, he asked his physicians to perform bloodletting on him. 124 – 126 ounces (3.75L) of blood was let out over a ten hour period by his physicians. The president weighed about 230 lb (104.5 kg) and was 75 in tall. Since the blood volume in an adult male is 70 ml/kg, his total blood volume was about 7.3 L. This means that, on the day he died, his physicians let out half of his blood volume. We know today that, that amount of blood loss leads to profound hypotension, shock, organ hypoperfusion and death. No wonder the president appeared calm before his death. He was probably in shock!
Luckily, there were men like Pierre Louis (1787-1872) and John Hughes Bennett (1812–1875) whose statistical analysis of medical data then helped put an end to the practice.

It’s not only beliefs and practices that have changed over time but also some drugs used. To mind comes mercury. A heavy metal, it is now known as a very toxic substance. It comes in three forms – elemental mercury, inorganic salts, and organic compounds. The organometallic Methylmercury is the most poisonous. Nowadays, mercury is found mostly in whale and dolphin meat, certain fungicides and skin lightening products.
It causes irreversible damage in fetuses, infants, and young children. It is damaging to the the neurons and causes cerebral infarctions, causing Minimata disease (Ataxia, Visual-field loss, Psychiatric disturbances, Sensory loss and Chronic Paresthesias). It is also toxic to the kidneys. The phrase “mad as a hatter” comes from the times when mercury compounds were used for the production of felt hats and led to the poisoning of the workers in the 18th – 19th centuries. So we can agree that mercury is bad.
Well, the Persians, Greeks and Chinese thought it increased vitality. The Chinese Emperor Qin Shi Huang died after ingesting mercury pills designed to make him immortal! From the 17th to 18th century, a drug called “Blue Mass”, containing 33% mercury was used to treat syphilis tuberculosis, constipation, toothache, parasitic infestations, and the pains of childbirth. From about 1930 till 1999, Thimerosal, a mercury-containing preservative was used in some vaccines. Thankfully, there is great awareness of the dangers of mercury now.

It is definitely a great time to be practicing medicine. Even as we hurtle along, ever adding newer drugs, treatment options and procedures to our armamentarium, lets not forget where we as healers have come from.

“Nothing that has value, real value, has no cost. Not freedom, not food, not shelter, not healthcare” – Dean Kamen

A young woman presented for a thoracotomy to remove a mass in her right chest. On my way to see her, her nurse accosted me and told me of the patient’s demands. She didn’t want to wake up in pain – fair enough – but she didn’t want an epidural either! It went on – no ribs were to be broken, she didn’t want a foley catheter and she wanted to be discharged the next day. I actually laughed out loud when the nurse told me this.
I walked up to the patient with a smile on my face that got wiped off by the chilly reception. I tried to explain to her that her demands were unrealistic. She wouldn’t hear of it. I called in the surgeon for reinforcement. We lost the battle. She walked out.
Now imagine there was a tool online that allowed patients to rank the quality of care they received at a hospital based on several questions about interacting with the doctors and nurses, like “Were they responsive to your needs?”
How do you imagine this young woman’s ranking will look like?
Oh yeah, there are already such online tools and it is interesting to read through them.
Which brings me to today’s question – “Using the responses from patients about their care in an inpatient setting, can one really extrapolate the quality of care received?”
My answer to that is big NO!
In medicine (and probably other professional fields too), there is always this big disconnect between physicians who actually take care of patients and those experts who hardly take care of patients so have time to make policy.
Irrespective of what so-called policy makers in some big institutions might preach, using patient satisfaction surveys as a window into the quality of care received in the inpatient setting is going down a very slippery slope of subjectivity.
Even surveys about patient satisfaction in the outpatient setting have been shown not to capture the real issue at hand but rather how long patients waited!
Healthcare is a huge sector. Certain sections can be evaluated using consumer feedback e.g nursing care, drug development, emergency care, public health, the control of chronic diseases. However, when it comes to inpatient care, do you honestly think you can get a patient to objectively tell you through a questionnaire how well a surgeon took out a tumor or replaced a heart valve or a knee or treated pneumonia or a heart attack?
How many of us know the surgeon with the hands of Asclepius but the demeanor of Sergeant Hartmann from the 1987 movie “Full Metal Jacket”?
What is mostly obtained from these patient surveys is the quality of nursing care and the human-to-human interactions. They also capture complications and I’ll come to that later. The reviews however miss the meat – the quality of medical care or surgical interventions.
Now, is it necessary for the public to have an idea of the quality of care they’ll get from a hospital? YES! Healthcare is a service industry and I think it is important for patients to have such a tool.
Let’s say you need to have a hip replaced. Imagine you could go into a tool that showed you each orthopedic surgeon in town, how many hips they did a year, which age group, which ASA class, length of a procedure, number and nature of complications, incidence of transfusions, length of stay and cost. Wouldn’t that be a much better tool than patient surveys?
Now how would such a tool be set up and populated? Setting it up would be the least of any developer’s worries. Populating it is the problem. The only way to get that information is to make hospitals report outcomes for each physician who works at that hospital. That way, consumers can compare. No hospital in the US is going to do that! They collect it but they aren’t sharing it!
And so policy makers grasp at straw by designing surveys based on patient experiences that seek to eke out the quality of care.
However, I think hospitals should publicize this data. It will allow competition in the marketplace, weed out the bad practitioners and lower costs. It will allow patients to choose the best surgeon for their needs. An ASA Class III or IV patient can look for a surgeon who does mostly ASA Class III and IV patients.
It also prevents doctors and hospitals from having to deal with policies that make practicing more difficult but do not really improve quality of care. I think we in healthcare should be more proactive in measures that bring patient care to a pact between a doctor and a patient, excluding insurance companies and government.
So next time you fill out a patient satisfaction survey, ask if it really captured the quality of care? It probably did not but these surveys can capture outcome in terms of complications. The question then is, “Are complications an indicator of quality of care?” To that I’ll respond with yes and no. Complications can be a window into quality of care or also very much patient related. Going back to hip surgery, if a surgeon does 350 hips in a year and out of that 50% have infections, there is a problem. However if a patient after valve replacement surgery with a mechanical valve goes home, forgets to take his warfarin and the valve clots off, that is on the patient.
As a consumer of healthcare, I’ll like to know what I’m getting when I walk in for a procedure. I wish there was a better way to tell than through subjective responses.