NSSC 2014 LogoThe Northern Surgical Skills Conference (NSSC) is a national conference held in UK in order to give medical students a better understanding of what a career path in surgery entails. The conference is an all-day event that features guest speakers from the field, opportunities to practice basic surgical skills, such as suturing and laparoscopy, and presentations from student researchers.

As a member of the 2014 NSSC Committee, I have had the rewarding experience of planning and coordinating this year’s event that is to be held on Saturday, May 17th. As we are drawing closer to the date and finalizing the last details, I stumbled upon a reflection that I wrote after attending last year’s conference as a first-year medical student. I feel that the piece highlights the importance of early exposure to different specialities for medical students; especially considering how the medical world is becoming filled with ever-increasing niche roles, requiring students to distinguish sooner-rather-than-later the path they wish to take.

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A simple but powerful video outlining the truths about the distribution of wealth in the United States. One can only wonder that if conditions are this bad in a “developed”, industrialized nation, how much worse could it be in other resource-poor settings with even larger poverty gaps.

Surely such skewed distributions will infiltrate and impact everyday life–especially for those at the tail-end of poverty, who lack resources for food, clothing and access to medicines. Clearly, this is a challenge faced by every nation in some form, regardless of GDP, and reaching that ‘ideal’ will prove to be an international dilemma that we must all tackle together.

1. Collaboration: decision making; identifying problems; formulating alternative planning activities

2. Execution: implementation; in carrying out activities; managing and operating programs/events/projects

3. Equality: economic, social, political or other benefits individually or collectively

4. Evaluation: feedback; making adjustments; partaking in efforts of growth and change

Remember in school how they always used to tell us to be “active listeners,” that we had to be “engaged” and open to learning. Participating in class extended beyond doing the bare minimum of facing forward, answering a question when called on, or doing your homework; it was a creative process—participation was taking an active role in shaping and forming the life of the class room by contributing your knowledge and opinions to the collective mind of the class.

If this is the case, then why is that we cannot uphold the same standards globally in the context of developing countries? We western first-worlders see ourselves as proctors to peoples and nations that are “less fortunate” or who seem to have gotten stuck between the cracks of modernization. With global networking—and no doubt, marketing—we are becoming more unified in our efforts to aid one another into a state of development. Now, the level of interconnectivity we have reached makes it so that the weakness of any one node is no longer isolated, but can drastically affect the progress of several other nodes that share ties with it.

Yet still, even with all our efforts of crusade, all the cash we have guzzled into Africa, Southeast Asia, and South America, these countries seem in no better conditions than they were decades ago—in fact, many of the inhabiting countries are progressively doing worse. In modern day we are allegedly in the hindsight of the failure that ensue neoliberal international policie, which attempt to completely re-route the structures of developing nations to resemble those of the modern west, using capital finance as incentive. Although, the rather recent example of the United States denying aid to Haiti—ravaged by a devastating earthquake and an outbreak of Cholera—until the country had agreed to the adoption of “necessary democratic legislation” would argue that we have escaped this modern colonial mindset.

Change cannot happen over night.

And, if change is to occur, it absolutely must come from the ground-up. Only through grass-roots movements can we work together to create sustainable structures and policies that are unique to each country, population and environment. Furthermore, our role as foreign aid, is to help in whichever way we can to allow the voices on the ground be heard up in the heavens. Participation, in its full capacity (see definition above), must manifest at the lowest tier—the poor; the sick; the hungry; the victimized; the gendered; the voiceless—and recognized (inter)nationally in order for true success to occur.

I recently came across one of the essays I wrote during my senior year at New York University in Spring ’11. At that time I was taking two of the most eye-opening and informative classes I have participated in to this date: Philosophy of Medicine and Visual Culture of Science and Technology.

Philosophy of Medicine explored how our society approaches medicine as a whole: What do we believe medicine should do for us? When should we access it? How? What roles do/should medical professionals play? What is their relationship and duty to their patient?

The second class, Visual Culture of Science and Technology, examined how our society reacts, shifts and changes with the introduction of new technologies and media. The majority of the class did focus on medical technology, and how advances in the field have shaped the knowledge and behavior of both medical personal and the general public.

Needless to say, both topics were absolutely fascinating, and the fact that each class was led by top-tier professors, Dr. Brad Lewis, a licensed physician and cultural theorists, and Prof. Marita Sturken, the Chair of NYU’s Department of Media, Culture, and Communication, only enhanced the experience overall.

As I was milling over the topics in these separate classes, I could not help notice a great deal overlap and some connecting themes. Ultimately, I decided to formulate an independent project in which I connected the two disperate classes via an essay piece that tried to use the tools provided by these classes in order to analyze the “dominant culture” of medicine (i.e medicine as practiced in western, industrial nations), and how our current medical practices are failing to provide optimum levels of healing for patients.

Now, after dusting it off and re-editing my work over these past couple of days, I find myself wanting to re-write the whole piece entirely to include the new knowledge and experience that I have gained over the course of this past year. But that is not the point. The piece is genuine and honest in its search for understanding. It explores over-arching themes of caring vs. curing, molecularization of the body via technology, the influence of visual mediums on medicine, and the structure of science in society.

It’s a longer read, but I do hope you enjoy it. And of course, feedback and idea contributions are always welcome. Click the link below for the PDF.

The Path to Humanizing Medicine

Finally, here we are: The completion of my project at ICDDR, B.

Below you will find a brief article describing the project–its development, aims and goals. The write-up is also to be featured in an upcoming Chronic Disease Newsletter published by the Center for Control of Chronic Diseases in Bangladesh (CCCDB).

Preceding the article is an album containing the powerpoint slides that were used during my final presentation. Click on the image below to view a gallery of the presentation slides, which outline and explain my project, using visuals and text.

CD Community Health Workshop Presentation

__________________________________________________________________________________________

-The Issue-

  More than three in five people will die due to chronic illness this year – a number that is steadily on the rise. According to reports published by the World Health Organization, chronic, non-communicable diseases make up the world’s number-one killer, claiming the majority of lives on the planet annually (7). Of this figure, 80 percent who are affected reside in middle and low-income countries such as Bangladesh, which has proven no exception to these trends. In fact, research has shown that the number of deaths related to chronic diseases in Bangladesh has only grown over the past decades, and will continue to pose a serious threat without proper attention (4, 8, 10).

Chronic diseases are characterized by several key traits, which include (6, 9):

  • Multiple risk factors
  • Require systematic, regulated treatment
  • Lack a cure; in most cases they are life-long diseases

Given their nature, chronic diseases are often quite difficult and expensive to treat, especially at advanced stages. However, due to their prolonged duration and latency period, there are several opportunities for prevention of these illnesses.

This is why it is becoming evermore crucial to address this issue in Bangladesh using preventative measures; especially in rural regions, which experience higher prevalence rates due to a lack of medical resources—doctors, hospitals and medication—and poor levels of health education and awareness (2, 3).

-The Plan- 

  Recent collaboration between ICDDR, B’s Public Health Sciences Department and Chronic Disease Unit has given rise to the creation of the Chronic Disease Community Health Modules as a potential form of intervention for rural communities.

The modules are designed for implementation as a workshop, consisting of a group of villagers (12~15) and one or two appointed facilitators to act as guides. Facilitators provide information and support to the villagers during the workshop, helping them understand the basics of the chronic diseases most prevalent in Bangladesh, namely Diabetes, Hypertension and Cardiovascular Diseases (5).

It has been specified that trial-runs of the project are intended to take place in Chakaria, an Upazila within the Cox’s Bazaar District. The site was chosen based on the location of ICDDR,B’s Chakaria Campus, which maintains close contact with rural villagers in the area via the local Village Health Posts that provide basic health services to the community (4). Additionally, there exist several grassroots Chronic Disease Clubs, where individuals can meet with a village doctor once a month in order to receive minimal assessment services, such as blood pressure monitoring. However, as of yet these clubs do not promote any form of chronic disease education, or further developed prevention-based intervention. This provides for a prime sample population that can be used to assess the potential benefits of the workshop, so that it may one-day be scaled-up and adjusted for use throughout various rural areas in Bangladesh.

-The Modules- 

  The workshop modules focus on the primary modifiable risk factors leading to chronic disease:

  • Unhealthy Diet
  • Physical Inactivity
  • Tobacco Use

The World Health Organization has emphasized that these three items need to be targeted as the first-line means of preventing chronic illness (9). Therefore, by providing information and tactics to navigate these risk factors, the modules may aid in spurring the community to make lifestyle changes necessary for guarding against chronic diseases.

In order to accomplish this goal, the workshop relies on ‘bottom-up’ techniques adapted from Participatory Rural Appraisal (PRA) – a method that facilitates local people to (1):

  • Analyze information,
  • Practice critical self-awareness
  • Share personal knowledge of the community to enact a plan of action

Thus, the majority of the workshop is focused on collaborative problem-solving in the form of group discussion and activities; not only are the participants able to learn about the causes and effects of chronic diseases, but they are also encouraged to examine the underlying systems and barriers in the community that perpetuate risk. Step-by-step instructions, discussion topics, activities, and scientifically verified informational charts and data tables are all provided within the contents of the manual to help guide facilitators to achieve these results.

In total, the manual contains four modules. The first serves as an introduction to chronic disease, and the following three sections are based on each of the primary risk factors. These are outlined in further detail below.

Module 1: Assessing Health and Illness in the Community

This primary objective of the first module is to observe general perceptions of health and illness held by the community. Participants review basic information on chronic diseases, while analyzing how outlying social and physical factors influence health and risk. 

Summary:

• Identify the current physical, social, and health issues faced by the community; examine as a group how these issues overlap

• Discuss the basics of chronic diseases: what are they, who do they affect and how

• Assess risk among participants and within the community

 

Module 2: Diet and Nutrition in Maintaining Chronic Disease

The module assists facilitators to discern general dietary trends in the community, as well as assess the participants’ basic understandings of nutrition. It also provides information and techniques in order to encourage participants to follow a proper balanced diet.

Summary:

• Observe dietary practices and assess dietary knowledge in the community

• Review the basics of nutrition: fruits and vegetables; fats, proteins, and carbohydrates; cholesterol and calcium; salt and sugar

• Assess participants’ learning and reinforce concepts and techniques to maintain a healthy, balanced diet

 

Module 3: Physical Activity and Exercise in Maintaining Chronic Disease

The module reviews the classifications and benefits of physical activity, and its role in guarding against chronic diseases. Not only do participants learn how to better incorporate balanced physical activity into their everyday lives, but they also have the opportunity to participate in a low-impact exercise session as a group for dynamic learning.

Summary:

• Survey seasonal trends that may lead to increased or decreased times of physical activity

• Review the benefits of physical activity and the five keys to incorporating it into everyday life: leisure/sport, house/yard work, occupational activity, self-powered transport, avoiding sedentary activity

• Partake in a group exercise session

Module 4: Tobacco Use and Maintaining Chronic Disease

The final module is designed for in-depth evaluation of the prevalence and effects of tobacco use in the community. An overview of both the health risks of tobacco use and the benefits of quitting give participants the opportunity to discuss ways to mobilize members of the community to quit or reduce smoking and chewing tobacco.

Summary:

• Uncover the root causes and influences leading to tobacco use in the community

• Review the risks, dangers, and health hazards of different types of tobacco use, including: smoking, chewing, and second-hand smoke

• Identify along the “spectrum of quitting” and discuss the personal, economic, and communal benefits to quitting tobacco use

Hopefully, the Chronic Diseases Community Health Modules will prove to be a comprehensive teaching and learning tool, growing in its potency over time. As they are now, the modules serve as a starting point for further development and refinement. As more individuals and specialists access the module—in full or in parts relevant to their work—they may provide their own contributions and feedback, continuing to enhance its effectiveness in addressing chronic disease not only in Chakaria, but eventually, throughout all of Bangladesh.

_____________________________________________

WORKS CITED

(1) Bhandari, Bishnu B. “Participatory Rural Appraisal (PRA).” Institute for Global Environmental Strategies (2003). Print.

(2) Center for Control of Chronic Diseases in Bangladesh. “Interaction between Chronic Disease and Poverty in Low- and Middle-income Countries.” Chronic Disease News 2 (Nov. 2010). Print

(3) Center for Control of Chronic Diseases in Bangladesh. “Chronic Disease Prevalence and Risk Factor Situation in ICDDR,B Health and Demographic Surveillance Sites.” Chronic Disease News 2 (May 2010). Print.

(4) ICDDR, B Periodical. “Chakaria Community Health Project Community Mobilization Toward Self-help for Health.” Glimpses 23.3 (September 2001). Print.

(5) International Center for Diarrhoeal Disease Research, Bangladesh. “Diabetes: The Emerging Epidemic in Bangladesh.” ICDDR,B Annual Report (2008): 7-10. Print.

(6) National Public Health Partnership. Preventing Chronic Diseases: A Strategic Framework. Rep. 2001.

(7) World Health Organization. 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases. 2008

(8) World Health Organization. Impact of Chronic Disease in Bangladesh. Chart. 2002

(9) World Health Organization. Preventing Chronic Diseases: A Vital Assessment. Rep. Geneva, Switzerland: WHO, 2005. Print.

(10) Zunaid Karar et. al 2009 – Epidemiological Transition in Bangladesh 1986-2006, Global Health Action

  Having worked in the service industry for several years now, and as a self-designated “restaurant explorer”, my attention was caught immediately by an article recently featured on National Public Radio. The write-up demonstrated how, when given the option to down-size a meal, coupled with information on the number of calories saved by doing so, the majority of customers opted for the smaller plate and tended to eat a more size-appropriate amount. Although it is not overtly stated, the writer seems to be hinting towards the idea that perhaps it should be responsibility of restaurants to offer healthier portion sizes in best interest of the public’s health.

Recalling the days I spent on the dinning floor as a waiter, I cannot readily imagine how it would be plausible for servers to follow a model based on the above study—that is, to suggest that customers order less at their own establishment. Firstly, servers are not nutritionists and are not trained to deliver health-related information. Moreover, this system seems to go against the principles of business. And lets be honest, the first priority of a restaurant is not to ensure their customers are living healthy lives, but that they are investing their dollars into the restaurant.

Still, it does make sense that it becomes much easier to help people control overeating if it is addressed ahead of time, before the food is put before them. Once halfway through a meal, temptation and socio-cultural motives (your mother’s reprimands to “finish your plate” ringing in your ear) make it harder to keep from over indulging. As noted by psychologist Janet Shwartz, lead author of the study that gave rise to these findings, “People are willing to downsize, but you have to ask them to do it.”

But the ultimate question is: whose job is it to ask the public to downsize?

  If individuals are unable to monitor their own eating habits, should it be a restaurants priority to restrict their diet. I have already argued against this notion. How about doctors? Of course, it is a physician’s duty to promote healthy lifestyles for his patients, not only to guard against disease but also to improve overall wellness. However, doctors cannot realistically supervise their patients twenty-four-seven; the only opportunities to do so are within the brief lengths of time during a consultation.

Finally, what of the government? Has obesity reached a point to which it can be considered a national—or even international—epidemic that requires fervent, federally-backed intervention. Some would argue that government involvement already oversteps its boundaries in both public and private affairs. I can only predict that such sentiments would exacerbate were there to be strong federal authority governing what we can and cannot eat.

So how do we go about tackling these issues?

  The United States has become quite infamous for its meal portions. When it comes to food, the general mantra in the U.S. has been “the bigger the better” or “the more the merrier”, in most cases. Whether it be combos, specials, “super-sizes” or meal deals, we have it all. Even during my own travels I have had foreigners from all over the world comment or ask about the rumored endless amounts of BBQ, burgers and fries in America. Fantasy and humor aside, such eating habits have led to dire consequences. As it was shown in reports published by the Organization for Economic Co-operation and Development (OECD), the U.S. remains a nation with one of the highest, if not leading, rates of obesity in the world.

What’s more, the Center for Chronic Disease estimates that as many as one-third (33.8%) of adults in the U.S. are obese. Rates among children and adolescents (aged 2-19) clock in at around 17 percent—that’s 12.5 million youth that are being affected and put at risk for developing a number of non-communicable diseases, including cardiovascular disease and diabetes, which are two of the leading causes of death in nation.

Certainly, “fast food culture”, sugar consumption, and the prevalence of fat-rich foods have been major contributors to this nutritional epidemic. These foods are ubiquitously available via the endless presence of fast food chains, vending machines and newsstands that sell all sorts of candies and chocolates. Nowadays, it is far more difficult—and expensive—to get hold of fresh fruits and vegetables as compared to the former food types.

  A report published by Washington University in St. Louis demonstrates how the rate of Type II Diabetes, which was previously known as “adult-onset diabetes”, has skyrocketed amongst adolescents, who continue to feast on processed foods laden with fat, sugar and salt.

A prime example of such trends and the risks they might bare is shown in the case of 17-year-old Stacey Irving, who resides in the United Kingdom. Ever since she was a small child, this young woman claims that she has eaten nothing but McDonald’s Chicken Nuggets—her lips have never touched fresh fruits and vegetables, according the report. Specialists have referred to her habits as a “chronic nugget addiction”, and have warned Irving that her monotone diet is seriously imperiling her health; note that that was after the teenager was rushed to the hospital after collapsing from breathing problems and severe anemia.

  Diabetes remains one of the leading causes of death in the U.S., and merely having the disease puts one at risk for a number of other health complications, including: high blood pressure, heart disease and risk of renal failure. Despite these threats, debates have continued to rage on how to address the dilemma of obesity—the most recent of arguments centered on federal involvement in navigating the issue.

Divides between whether or not the situation has reached the point of governmental regulation is most aptly articulated in a live debate between two teams: Dr. Pamela Peeke, WebMD’s Chief Lifestyle Expert, and Dr. David Satcher, the 16th surgeon general of the United States, forming the team in favor of dietary regulation via federal involvement; with Paul Campus, a law professor at University of Colorado in Boulder, and John Stossel, a host on the Fox Busines Network, forming the opposition.

Both Dr. Peeke and Dr. Satcher take the position that it is a government’s duty to protect the lives of its peoples—even from their own doings or habits. Satcher notes that “between 1980-2000, the rate of obesity has tripled among youth and doubled among adults”—an exponential rate that has had strong correlations with the numbers inflicted with chronic illnesses in the nation. Peeke also supports that the crisis has grown to levels that can no longer go overlooked. Her concerns go far beyond merely “demonizing sugar,” and she openly states she hopes a spectrum of industries, backed by the government, can synergize their efforts to tackle the issue that is threatening the U.S. population.

  On the other hand, Campos argues that a population-based approach only serves to weaken the argument that obesity is the government’s business. “We do not know how to produce long-term weight loss…we do not even know if long-term weight loss would be beneficial,” states Campos, pointing towards a gap in scientific research data. “The [one] thing we do know is that public health interventions designed to produce weight loss, do not produce weight loss…in children or adults.” Moreover, Campos fears that the public will interpret government mobilization as an aim to “eliminate body diversity.” This last concern, I believe, is particularly noteworthy: It is true that bodies come in all shapes and sizes, and we have been taught—by our parents, by the media, and by many educational institutions—to love the skin we are in and accept our body as is; with this mindset in place, it would only be natural that some may become viscerally defensive against any actions that take place to change their body, especially when imposed by the government.

Similarly, Stossel echoes notions that denounce government right to intervention. He even goes so far as to label such an initiatives as a “formula for totalitarianism,” warning us that allowing the federal authority this much power over personal choice will turn it into a “leviathan who plans our meals.”

  Sadly, the critiques brought up by Campos do not seem to be too far from the truth: we continue to struggle in finding a healthy, sustainable public health intervention for weight loss. Especially within recent decades, it has become increasingly popular to turn to invasive, “quick-fix” procedures in attempt to remedy the problem with haste. In cases of extreme obesity, some insurance plans now help cover the cost for patients seeking procedures such as lap-band placement (putting a constricting silicone ring around the stomach to help restrict food intake) and gastric bypass surgery (surgically own-sizing the stomach itself).

Some doctors now push for these procedural forms of intervention as an alternative to the grueling experience of dieting, which often produces cyclical trends resulting in failure. But, addressing health with said “magic-bullet solutions” has never proven to be as successful as we have hoped; we cannot expect successful, sustainable outcomes without doing the groundwork. This notion applies particularly to cases of obese adolescents and teenagers, who are many times led to believe that they are merely one operation away from achieving their goal weight and attaining their dream body.

  The New York Times followed a 17-year-old morbidly obese American girl, Shani Gofman, as she went through such a process. At the tender age of 18 she underwent a surgical lap-band procedure under the guidance of her physician. Prior to the surgery, Gofman was warned by her doctor that she would have to monitor her diet; she would no longer be able to eat the portion sizes she had previously been used to, due to the restricted size of her stomach. Gofman reassured him of her commitment. But saying you will do something and actually following through on those words are two difference things.

At first, all seemed to go well with the procedure, and Gofman began seeing results. However, it was not long until old habits resurfaced, and Gofman began to slip on her diet, consuming food in larger quantities and at a faster pace. This, compounded with financial and personal reasons that deterred her from attending her routine check-ups, culminated in a backsliding of her progress. Gofman began to regain her weight.

Although the final number of pounds the teen weights at the end of the year is never stated, we are left to assume that it is less than satisfactory. Clearly, when it comes to food, diet and nutrition, the influences are multifaceted and complex—quick fix solutions are bound to fail without the proper support or education. Dr. Wendy Scinta, a family practitioner based in Syracuse, New York, sums up the underlying theme of this account rather succinctly: “I think it’s pretty extreme to change the anatomy of a child when you haven’t even tackled the other elements.”

  It has become obvious that tackling obesity will surely prove to be a great challenge within the health realm. However, one thing remains certain: if we hope to create any form of sustainable health change regarding diet around the world, it’s going to have to start on the level of habit, which is no easy feat.

What one chooses to eat is an entirely personal decision; you cannot force someone to eat healthily. We can place laws that govern and prohibit inherently dangers or destructive behaviors (drug use, murder, theft, etc.), however eating in itself is a completely natural and necessary act—it only becomes endangering to one’s health after a certain point. Thus, justifying and normalizing any form of governmental intervention will surely prove difficult.

  This makes it a little more difficult for policy to directly target obesity. Rather, we must rely on campaigns and policy that may help curb public appetite towards getting their 5 fruits and vegetables a day, rather than a burger and bag of potato chips. One such example is demonstrated in a recent initiative executed in New York by the Health Department, which was meant to deter citizens from overeating, and instead encourage them to control their portion intake, especially in regards to fast food:

While the intentions of this health campaign were noble, the execution was rather sloppy. It was discovered that the man’s “amputated” leg in the poster had actually been Photoshoped, and the man himself was not know to be diagnosed with diabetes. The NYC Health Department took a blow for “falsified” advertisement, which ultimately discredited their message.

Other proposal have included placing higher taxes on food products such as sugar, in hopes of deterring individuals from buying and using these food products. But still, others argue this will only cause those with limited economic resources to use more of their money on sugar, leaving less money available to buy healthy and essential food products.

  And these circumstances are by no means limited to the U.S. or other industrialized nations alone. In fact, adding an international scope to this health crisis only serves to complicate an already disputed issue, highlighting its severity. Ever increasingly, low and middle-income developing countries are also facing similar health challenges. National Public Radio reported on the health concerns that are arising alongside China’s middle class, who now have access to the “pleasures” of western fast food. China’s economic growth has led many to adopting similar eating patterns to that of the U.S., as noted by market researcher Paul French. “More, more, more of everything — larger portions, with more ingredients, more salt, more sugar, more oil, more fats.” Needless to say, this has correlated with an increase in the number of health risks and complications that are tethered to unhealthy diets.

  Howe we decide to address these trends within the upcoming years will prove to have an immense impact on the international health arena. While we may continue to argue as to who has the sovereign right to intervene on the public’s “personal choices”, it still does not change the fact that chronic diseases remain the leading cause of death globally—among such illnesses, Diabetes and Obesity have taken their place as major contributors to the endangerment of health. One way or another, we have to change our habits, our culture and our relationship to food in order to promote healthier bodies and lifestyles. Of course, we should enjoy the pleasures of food and the beautiful power that a meal has to bring people together; but remember that good things are best in small doses: Moderation is key.

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