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Thursday, September 29, 2005

Local Cuban Health Care

Tell Us What Castro Does

Dr. Lester CN Simon

Something odd is happening here. Take a walk through any of the wards at Holberton Hospital and you will see the plight and paradox of our nurses. Local nurses have left Antigua and Barbuda in droves and Cuban nurses have arrived in their stead. Despite the kind assistance from Cuba, there is a chronic shortage of nurses in the state and our nurses are still under extraordinary pressure. The oddity here is that there is something fundamentally “un-Cuban” about the relationship between Antigua and Barbuda and Cuba regarding the attempts to solve our nursing and some other medical problems.

I have never been to Cuba. I have read about medicine in Cuba in medical journals. I have discussed the practice of medicine in Cuba with doctors who were trained in Cuba. Most important, I have observed Cuban medical workers, including nurses, right here in Antigua and Barbuda.

President Castro would agree with the adage, “Give a man a fish and you feed him for a day. Teach him how to fish and you feed him for a lifetime”. What do you think President Castro would do if Cuban nurses migrated and the nursing service in Cuba started to decline?

I think President Castro would get a piece of paper and ask the nursing tutors to write down all the duties of a typical nurse. He would then ask the nursing tutors to get two separate pieces of paper. On one sheet of paper, the tutors would extract from the master list of duties, all of the duties that must be performed by a trained nurse. On the other piece of paper, they would write all of the duties that can be performed by someone who does not have to be trained as a typical nurse. Castro would then discard the paper with the master list of nursing duties, hold up the other two pieces of paper in both hands and decree, “Out of one nurse, many workers”.

In Holberton Hospital, we have staff nurses, registered nurses, nursing assistants, ward assistants and, at times, student nurses. The staff nurse is in charge of the ward. She must be trained for 3 years to become a registered nurse and then she has to successfully complete a post-basic 1 year course such as midwifery. The nursing assistant and the ward assistant require 18 months and 6 months of training, respectively. The nursing care of a patient is a manifold function including making the bed, bathing the patient and other forms of personal care, giving oral and injectable medication, taking blood and other samples from the patient, dressing wounds, conversing with the patient’s relatives and other visitors, recording vital signs such as pulse, temperature and blood pressure, writing nursing notes about the patient’s condition, supervising and teaching auxiliary staff, planning and implementing nursing care, and making rounds with the doctor, to name a few.

In the absence of sufficient staff, a staff nurse has to perform many of the duties that can be done by a registered nurse, a nursing assistant or a ward assistant. Added to this, a staff nurse finds it difficult to continue to accept the fact that similarly trained government workers, indeed some who have undergone less training and who are doing less work, are paid much more than a staff nurse.

But that is only a tiny part of the story. A similar financial disequilibrium is seen all across the paramedical field, in medical laboratory technology, pharmacy, radiology and physiotherapy. Equal work should not have to beg for equal pay.

Observation shows that some Cuban workers, like some laboratory technologists and some nurses are very good in some aspects of their work to the exclusion of other, interrelated parts. It is clear that many of them were very well trained to suit a particular job function. This is in contrast to our local medical laboratory technologists and nurses who are first trained generally and then secondarily as specialists. Our training in many areas is equivalent to understanding the whole hand and then specialising in a particular finger. In many instances, training in Cuba for some medical workers seems to be the equivalent of mastering the details of a particular finger from the start.

The digital approach in Cuba makes sense to Cubans because all able Cuban citizens must contribute and all must be educated, housed, clothed, fed and be happy. Additionally, it initially ties the workers to their country since their skills are part of a larger, integrated system, without which these workers are not very marketable internationally. In time, the worker can easily augment their expertise and step over from one digit to another to cover the entire hand. By this time, the state has benefited enormously from the erstwhile digitalised workers.

President Castro would tell us that we have to attract more workers into the positions of ward assistant and nursing assistant while we continue to train more nurses. The ward assistant and nursing assistant must be given the opportunity through well designed courses to go on to become nurses. Trainees in other paramedical fields, like laboratory medicine, should be allowed to pursue a similar path. But President Castro knows that all these trainees will only enter the field and accept these opportunities if they are paid the equivalent of what similarly trained and equivalent government workers are paid. President Castro knows that equal work demands equally high or equally low wages.

It is not just what Castro said. Rather, it is what we said to President Castro. Somebody is not telling him the truth. When we do, we will reap the central benefit of the Cuban revolution, which is: applied education for the good life that all of us want to live. The sad part of this medical assistance drama is that like Cuba, we need a revolution in medicine in this country and our path to success is so much easier than Cuba’s. But then again, President Castro would probably tell us that the hardest revolution is the revolution of the mind. Unfortunately, unlike President Castro, history will not absolve us.

Thursday, September 15, 2005

Big Big Big

Big Belly and Big Bottom

Dr. Lester CN Simon

Take a midday promenade along Market Street from Newgate to the market gate. Try to classify all the people you see along the way. Ignore the fact that some of us are as ugly as a rusty, bent-up, tin can-cup. Ignore that fact that some of us are as good looking as a tall glass of iced, good water quenched against the salty lips of a beaded face sweltering in this satanic, September sun. Disregard the slender ones that will make uncooked macaroni look fat. Just regard the big, fat “one and them” with big belly and big bottom.

Everyone knows that a big belly is not as healthy as a big bottom. Science has come to the same conclusion. It is good and pleasing when common knowledge and science see eye to eye because science is simply organised common sense based on careful observation.

Excessive fat or obesity increases the chance of getting diabetes, harbouring excess, bad fats in the blood stream and having complications involving the heart, brain and blood vessels, to list a few. However, all body fats are not created equal. Fat that is accumulated inside your belly (the apple shape) is much more dangerous to health than fat accumulated under the skin in the region of your bottom (the pear shape).

Since the location of excess fat is more relevant than the amount of total body fat, scientists have been trying for many years to understand what makes a fat belly so dangerous compared to a fat bottom.

Earlier this year, scientists in Osaka, Japan identified a new substance that is produced in much greater amounts by belly fat than by any other part of the body. They called it visfatin because the word “viscera” is used to describe the organs inside the body including the organs inside the belly. These organs can become surrounded by fat and cause the big belly.

The scientists discovered that the more belly fat you have, the more visfatin the belly fat would produce. The next step was to determine the effects of visfatin. Since visfatin is made by the bad, belly fat, common sense suggests that visfatin would do some bad things to the body. For example, belly fat increases the risk of getting diabetes. Hence it was suspected that visfatin would also increase the risk of getting diabetes by raising the blood sugar.

To the surprise of the scientists, visfatin does the opposite to what was expected. Visfatin actually reduces, not increases, the level of blood sugar. In fact, visfatin acts on blood sugar just like insulin. Why is visfatin, a substance produced by the bad, belly fat, acting in a good manner like insulin? Does this mean that a big belly may not be so bad after all?

Scientists are still investigating the role of visfatin. They have encountered an intriguing paradox. On one hand, visfatin from belly fat acts like insulin by lowering blood sugar. Visfatin also acts on the very belly fat that produces it and so gives rise to more belly fat, which in turn produces more visfatin. On the other hand, the excess belly fat can also make substances other than visfatin. These other substances may cause a rise in blood sugar and increase the risk of getting diabetes, raising bad cholesterol and having complications involving the heart, brain and blood vessels.

It would seem that belly fat is like a two-edged sword. It makes visfatin, which can act like insulin and lower blood sugar, which is good for a diabetic. But belly fat also manufactures other substances that have bad effects including raising the blood sugar, which is bad for a diabetic.

Notwithstanding the newly discovered good effect of belly fat, when the bad effects are taken into account, it is better to avoid having a big belly altogether. It seems that, as we so often discover in life, there is good and bad in all things and we must consider and weigh them all to find the balance point.

The study of fat is very important. There is good fat and bad fat in both the type of fat and the location of fat. Pound for pound, you get more energy from dietary fat than you get from either protein or carbohydrate. Fat produces substances that can help to boost the immune system to fight germs. In fact, some scientists note that visfatin is not a new substance and that it was discovered years ago and called by another name because it was known as a booster to white blood cells, which fight infections.

Fat, in moderation, was once a sign of good health. Some scientists consider fat to be the largest organ of the body and they have discovered that fat is the producer of many hormones that affect many parts of the body. Many of those scrawny, match-stick models on the catwalk, whom some people admire, are plagued with myriad medical problems.

One day, scientists may discover the bad effects of a fat bottom compared to fats in other areas. Fat chance. Until then, continue your walk along Market Street and, with due attention to the vehicular traffic, do not be too modest if you find yourself looking back despite your best effort to walk straight ahead.