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International World No Tobacco Day 2012 – Feature Article

– by: Dr. Aishath Aroona Abdulla, Maldives Medical Association –

Tobacco Industry Interference with Promoting Good Health

On 31 May every year, the world commemorates World No Tobacco Day. This day has been set apart to give an opportunity to educate people worldwide and to help nations to focus on interventions for tobacco control, because tobacco is an extremely hazardous and highly addictive substance, causing a great deal of death and suffering, and needs special collective efforts by a multitude of groups and individuals to control its use and consequences.

Tobacco was introduced to the world after Christopher Columbus landed in America in 1492. It was since transported to other countries across the world and within 150 years, has become a major trade commodity with a huge market internationally.

Tobacco is a major health hazard, causing 6 million deaths worldwide every year. 600,000 of these are non-smokers exposed to second-hand smoke. Tobacco kills one in every two users of tobacco, and it kills slowly, bringing much suffering – physical, mental and social – over several years before finally killing. Scientific research has proven that tobacco causes many illnesses involving almost all the different systems in the body, and affect people of all ages, particularly children and pregnant women. Some common illnesses include stroke, heart attacks and many illnesses of the respiratory system that become irreversible later in adults, in addition to lung cancer and many other types of cancer. Second-hand smoke causes asthma, pneumonias and many other respiratory illnesses in children. Exposure to tobacco smoke in pregnancy causes abortions, premature delivery, small for gestation babies and can lead to sudden infant deaths (SIDS). Newer research also suggests that exposure to tobacco smoke in early life may be associated with certain disorders of brain development. And no benefits have been shown to-date despite extensive research. In Maldives, it is estimated that tobacco accounts for more than a quarter of deaths. Thus tobacco is a hazardous substance that should be strictly controlled.

Tom And Jerry Slapped With Smoking Ban. by Stuart Heritage on August 22, 2006 http://www.hecklerspray.com/tom-and-jerry-slapped-with-smoking-ban/20064524.php

If tobacco were not harmful to health there would be no reason to control its use. Four cigarette manufacturers dominate about three-quarters of the global market. These are very wealthy, trans-national companies, thus yielding immense power, above that of individual nations. Tobacco companies work for profit. They resort to various devious tactics to increase their sales.

  • Tobacco industry targets low and middle income countries
    • Many developed countries have now made strong laws that prohibit smoking in public places, prohibit advertising, restrict production, import, sales, and tax tobacco heavily. These are proven methods to reduce tobacco consumption and thus the harm. Tobacco industry knows they cannot sell in these countries, and so specifically target low and middle income countries which have poor laws and low education among their population. Nearly 80% of the world’s one billion smokers live in low- and middle-income countries
  • Tobacco industry targets children– tobacco companies know that tobacco causes premature deaths. So they want to recruit more smokers to make up for the loss from premature deaths. They specifically target children by interfering with laws, specific advertisement and promotion in films.
    • In the United States, 390,000 kids are recruited to smoke each year by the smoking they see on screen, worth $4 billion in lifetime sales to the tobacco companies.
    • Do your kids see smoking in movies in Maldives?
      • Check the cartoons – e.g.
      • Check the cable TV channels – they may not be regulated under our laws.
      • Movies from the internet (e.g. YouTube) are not regulated at all. Many teenagers in Male’ watch films off YouTube.

Tobacco companies target the youngest children possible. Younger the child, the more lasting the impression, the higher chances of taking up smoking, and the harder to quit.

  • Tobacco industry targets women– “women are vulnerable” they say. Actually, they know that if a mother smokes, it increases the chances that her children will smoke , creating a whole family and generation of smokers. They specially advertise to women since post-world war 1920’s, when they deceived women into associating cigarettes with women’s rights.
    • In 1929 – a tobacco company hired Edward Bernays (named by some as the father of public relations) to stage a  parade in New York City, showing models holding lit Lucky Strike cigarettes, that they called “Torches of Freedom“. Women immediately associated it with women’s rights, and smoking increased among women. Today, many women still think it is a woman’s right to smoke, while tobacco slowly kills more women.
    • In modern times, tobacco industry advertises that cigarettes help loose weight, showing models with slim figures, while in reality, smokers lose their appetite, and become thin and wasted.
    • New types of cigarettes like “Lights”, flavoured cigarettes (mint, strawberry, etc. are specially targeted for teenage girls.
    • (“Lights” are a misnomer. They claim to have low tar, but actually have low nicotine, that makes people smoke more cigarettes and spend more of their money, while exposing themselves to the same risk or higher, of getting ill.)
  • Tobacco industry advertises in devious, indirect ways
    • Movies – they use a method called “product placement”. Film-makers are paid to add scenes where main characters are shown to smoke in various situations, and can be depicted as rebellious, fun, stress-relieving, the list goes on. Brands are often displayed in the film. This is an underhand way of sending messages to the unsuspecting brain, where people don’t realize that they are seeing an advertisement. Big Tobacco pays actors, actresses and producers to get their products into the movies.
    • Using role models to entice young adolescents to smoke – e.g. actors smoking off-screen, paid models smoking in places young people frequent, like shopping malls, supplying free cigarettes to film-stars and armed forces officers to entice young boys to smoke, etc., especially where advertising is restricted.
    • Philanthropy – They sponsor sports, arts charity events, etc. to get sympathy and “show people they do good”, while they kill millions of people worldwide (estimated 600 million deaths per year)
      • Tobacco industry distorts scientific research – As scientific research increasingly proved that many illnesses, like lung cancer, and an extensive list of other illnesses are caused by tobacco, the industry hired scientists to write to journals and lay media questioning these research, and stating that these findings are doubtful. This helps to keep their consumers. People continue to not worry about smoking when they are not sure if it causes illness. Many diseases are actually proven to be caused by tobacco, several by good scientific research studies with large numbers of participants and good study methodology.
      • Tobacco industry lobbies politiciansand political parties in most countries. – They do this to prevent good laws, make loopholes for them, so that they can continue to “do business”. They make monetary deals, bribe, fund election campaigns, and even send false “experts” to give unsuspecting governments advise against making solid tobacco control laws.
        • Joint manufacturing agreements: Tobacco companies form joint ventures with state monopolies and subsequently pressurize governments to privatize monopolies
      • Creating Smokers’ rights groups: Tobacco industry make an issue and create their own supportive groups to create an impression of spontaneous, grass-roots public support. These include: Smokers’ rights groups, women’s rights groups, tobacco farmer’s groups, tobacco company workers’ groups, tobacco seller’s groups, and even so-called “consumer groups”. These are fake groups. Tobacco companies bring out issues as if they affect these people severely, and make the people gather together to “stand up for themselves”, while they actually fight to make the companies richer.
      • Intelligence-gathering: Tobacco industry carries out regular market study and researches on how they can create demand by influencing how people think to promote their products. Thus they are often ahead of public health authorities.
      • International treaties: Tobacco industry uses international trade agreements to force entry into closed markets and limit countries ?form increasing taxes. Now, however, the World Bank no longer supports tobacco industry (including tobacco farming) with any type of funding or concessions.
      • Intimidation: They use legal and economic power as a means of harassing and frightening opponents. They have filed court cases in countries that introduced smoke-free laws, e.g. India

      How did this information come out?

      In earlier days, tobacco companies would openly advertise that their brand did not bring cough, or were safer, etc. As people who got cancer learned from doctors and medical evidence that tobacco cause lung cancer, they sued the tobacco companies for lying. That is how many of these company secrets leaked out. Today, health authorities follow them stringently and try to identify their strategies. Still tobacco companies are ahead, because they have wealth and power, and conduct regular market research.

      The solution:

      Tobacco is difficult to control due to its addictive nature, and due to the influence from tobacco industry. Therefore the World Health Organization (WHO) established a special Tobacco-Free Initiative in May 2003, to focus on tobacco control, and prepared a treaty called the Framework Convention for Tobacco Control (FCTC) which came into effect in February 2005. WHO FCTC recommends a package including multiple methods of control, named the MPOWER package. To-date, 174 countries including Maldives are signatories to the FCTC. By signing, a country agrees to commit towards tobacco control by establishing the strategies of the MPOWER package.

      All these methods are proven to be effective. However, the size of effect of a single intervention is relatively small, therefore WHO recommends that all these interventions be used in combination to control tobacco and tobacco-related disease effectively.

      So it is important that we as a nation carry out all these methods to prevent harm from tobacco in Maodives. Act now.

      Towards a Tobacco-Free Maldives.

       

Categories: Issue 27: June 12

New Wheelies …

It is not very often that we look at how new technology and innovations may matter in very small things that matter. Given the complexity of a hospital’s operation, one would think that a wheel chair is a very simple matter. However, modern technology has been in full force to make modern wonders in all aspects of patient care. Of course as our visions states, to be the leading healthcare provider in the country through innovation and excellence, ADK Hospital also looks at such developments closely and tries to implement modern technology.

This new wheel chair is far from what is seen. Many people have curiously looked at the new wheel chairs at ADK Hospital. These wheel chairs are state of the art innovations for modern hospitals. This wheelie is known as the Space Saver and sets new standards for quality and functionality. This new product provides patient transfer in an easy and comfortable way both to patient and the caregiver.

Hospitals, with all the crowd and “traffic” in it, resemble the disorder of cities. In order to minimize this chaotic situation and make the environment tidier, the park station makes it really convenient when in need for space.

Patients are already feeling the ease and comfort of the chair with positive feedback to the Hospital. We hope that little things that matter can be improved in future too and make the patient more comfortable while in the care of our team.

Categories: Issue 27: June 12

World blood donor day

Every year, June 14 is marked as world blood donor day. According to the World Health Organization, June 14 is marked as the day to recognize the millions of people who save lives and improve the health of others by donating blood. The Day highlights the need to regularly give blood to prevent shortages in hospitals and clinics, particularly in developing countries where quantities are very limited.

In the Maldives, there is a very high need for blood donation and requires major public awareness on blood donation. This year the theme is ‘every donor is a hero”. Rightly so, we donate blood to save lives. With an endemic thalasaemia situation and more than half of the pregnant women in the country being anaemic, the need and the potential need for blood is very high.

Despite the need, there are many challenges. Firstly willing donors are scarce. Perhaps myths associated with donation. Major awareness creation is needed.

Secondly banking facilities are scarce too. To be exact, national banking still has issues and is highly limited. Especially for islands the situation is extremely bleak. Hence, it is imperative that such issues are addressed.

ADK Hospital also puts some effort to introduce blood banking. At present major equipment is installed and training is ongoing. It is envisaged that the blood bank will be in full swing by end of July.

To celebrate the blood donors day, the hospital ran a donor registration and awareness creation clinic for the day. Although it was not a major attraction, considerable achievements were made to collect potential donors for the proposed blood bank.

Categories: Issue 27: June 12

I’m a doctor. Must you trust me?

By: Dr. Faisal Saeed
When Luke Fildes painted The Doctor in 1891 as a tribute to the status of the English doctor, it was heralded by the doctors at the time as a symbol of their profession. The painting depicts a well-dressed doctor sitting by the bed of a young patient contemplating on the next course of action, with his gaze fixed on the patient. The patient lies in bed with a hand held out in supplication. The father of the patient stands in the shadows, with a comforting hand on the distraught mother, looking at the doctor, waiting for his assessment. If need be, the doctor will dispense some medication. If need be, he will roll up his sleeves and operate. The painting was drawn at a time when there was little doctors could do in terms of treatment. Yet the family places their trust in him fully, and the doctor is allowed to get near the child that they value and love, with the belief that the doctor will act for the benefit of the child, instead of harming him. There is uncertain knowledge about what action the doctor will take and the family depends on the doctor’s ‘expertise’ to cure their child. This vulnerability, uncertainty and dependence forms the basis of trust, and in many ways, the sense of trust that emanates from this iconic picture is characteristic of the trust public places in the medical profession.

The Doctor, by Luke Fildes

The doctor-patient relationship is one that is grounded on trust. There is a tacit belief in the doctor’s goodwill and competence, resulting from an imbalance of power between the patient and doctor in terms of knowledge. And where there is ignorance, and uncertainty, trust is a must. The lack of knowledge seems crucial to the notion of trust. Even where knowledge is possible, as when the patient is a doctor himself, he must feign ignorance, because trust is described as one of the virtues of being a good patient, together with truthfulness, justice, and probity. Trust is required because medical care depends upon judgement calls that are not predictable, and the good patient is one who recognizes this. A doctor is not allowed to treat himself as his judgement is deemed clouded when sick, and he must submit to the treatment of other doctors and pretend not to be certain of outcomes. The struggle here is obvious, and it is not surprising that doctors qua doctors turn out to be the worst of patients.

A trustworthy person is someone who has a quality that we desire, and we trust our doctors to have goodwill towards us and to work in our best interests. The burden of trust mostly rests on the doctor because he has to work for our best interest, while being impartially concerned for our wellbeing. When we put trust in our doctor, we do so on the assumption that the probability of him doing what is beneficial to us is higher than what is detrimental, high enough for us to consider cooperating with him. Trust therefore enables patients to co-operate in making clinical decisions together. But while the doctor’s goodwill towards the patient would be desirable, it is not a necessary condition for trust. The patient may well know that the doctor bears him little good will and regards him as a gomer, yet trust him to treat him competently. The patient only has to trust the doctor to provide a good outcome for the patient. For his part, the patient could regard the doctor as a ‘dirtball’, be seductive or deceptive, or even pretend to be ill and the doctor would still have to treat him.
Trust also works to reduce the many complexities that arise in the modern health care setting. Medicine has become complex and highly technical, and it does little good for the patient to know every detail to guide the surgeon’s hands, or to know all the side effects of each medicament or all the complications of every procedure. The patient can rely and depend on the doctors to process this complex information. In the therapeutic setting, trust is instrumental because it encourages positive health behaviours such as seeking medical help, revealing sensitive information, consenting for, submitting to and complying with treatment and returning for follow-ups when advised. It is also therapeutic in the sense that it promotes healing (the placebo effect is a striking example). Trust fosters an effective healthcare relationship and also acts to promotes the doctor’s job satisfaction. Conversely, if this trust were lacking, patients are more likely to seek second opinions, to switch doctors, resort to self-treatment or alternative forms of treatment, conceal information that may be key to diagnosis or even decline to take up preventive measures such as vaccines or comply with treatment in general. The predilection of our patients to fly abroad, even for available treatment, could also be a symptom of the general lack of trust, be it in our doctors or in the system.
Trust therefore functions to provide the context which enables the uptake of the benefits of medicine by the public. In doing so the public places its trust in both the doctor and the medical system or the medical profession. Trust for the physician derives from his professionalism and mannerisms, and the doctor-patient relationship reflects aspects of enduring emotional bonds that form early on in life, amplified cognitively over time. This trust is interpersonal and patients act under conditions of uncertainty, and choose to trust the doctor, with the assurance that the doctor will accept responsibility when this trust results in disappointment, or harmful outcomes.
A lot of trust is hence evidently placed in medicine. What matters is not the amount of trust,  but whether this trust is well placed or not. The paternalistic conception of the doctor-patient relationship does not provide a context to put reasonable trust in because of the power and knowledge asymmetries between the doctor and the patient. Trust is only well-placed when the patient and the doctor are on an equal footing through more information and less dependence. There is a loss of context for the traditional forms of trust to arise because of considerable changes in the practice of medicine. Firstly, it has become more technical and less personal. Unlike in Luke Filde’s painting, the doctor’s gaze has come not to be fixed on the patient, “that concrete body, that visible whole, that positive plenitude that faces him” but towards…“the signs that differentiate one disease from another,” on lab reports, x-rays and the numerous equipment to which the patient is connected. This biomedical model of medicine deprives the patient of every moral and social dimension, and decisions taken at the bedside become technical and efficient, but unemotional. Secondly, patients are beginning to be more empowered and are more (if not always accurately) informed about the medical care, and are encouraged to be seen as partners in health care decision-making. The right of the patient to be informed on treatment and the right to refuse or accept treatment is well established, and professional paternalism is discouraged in modern medical practice. Instead of waiting in the shadows as a background figure as in Filde’s painting, the father would be very much in the spotlight, participating in making decisions with the doctor. In this context the patient takes on a position of trust-as-confidence rather than trust-as-faith because what necessitated trust as faith, goodwill towards the patient and lack of information, are no longer present.
While it may be said that there is a loss of the context for trust to thrive in, with the change in medical practice, the general decline of trust in social and political institutions, weak medical regulation, more empowered patients, and a  public suspicious of failings on the part of doctors, it remains yet to ascertain if there is a crisis of decline of trust in the medical profession. However, as Justice Irwin states: “Public trust in doctors is essential to the whole enterprise of medicine. A destruction of that trust would be corrosive to the general attitude to the profession and therefore to the effectiveness overall of treatment”.
Categories: Issue 27: June 12