Heat Exhaustion Kills Diabetic Hypertensives in the Philippines

Yesterday was another hot day. They say it's the hottest since January this year. This may not also be the last in the 'hottest' series, as the temperature can still get hotter.

What really matters here is not only the recorded temperature, but how it really feels like out there with this kind of temperature.

AccuWeather.com calls it the RealFeel Temperature and it takes into account the effects of multiple parameters, including ambient temperature, wind speed, solar intensity, humidity, precipitation intensity/type, elevation and atmospheric pressure.

In the case yesterday, for example, that 37.3°C really felt like 40°C or a scorching 104°F.

Why so? Because of humidity and because heat can't really be dissipated in an environment like Metro Manila. The concrete roads and cemented surroundings absorb heat and stores it long after the sun has set.

Why is this important? What happens when it becomes hotter?

 Inquirer.net, 27 April 2010

News reports previously attributed the death of the former governor above due to heat stroke. I think it's a misnomer. Here's another case reported yesterday:

Manila Bulletin, 28 April 2010

Anyone who collapses here amidst a hot weather is termed a 'heat stroke,' but a heat stroke means having a temperature of more than 40°C due to heat exposure and abnormal thermoregulation. I strongly doubt both the governor and the cop's temperatures were taken at the time of their respective fainting spells.


What probably happens is simply heat exhaustion.


What ultimately kills them is a myriad of other factors.


In the governor's case, there was a confluence of diabetes, hypertension, and exhaustion from campaign activities. This was a fatal cocktail that led to a cerebrovascular stroke, and as reported, the governor was semi-comatose after his brain surgery. 

In the cop's case, it was clearly heat exhaustion complicated by head trauma when he fainted and hit his head on the cemented floor.

"A CPPO report said that Alivio fainted as he and his colleagues were having tae bo at the camp’s open basketball court at 4:30 p.m. Tuesday. Tae bo is an exercise program combining elements of boxing, dance and tae kown do, a Korean martial art.

Alivio sustained bruises on the forehead when he collapsed on the cemented court. " ~ Manila Bulletin, 28 April 2010

Too much heat can certainly cause blood pressures and tempers to rise. Drinking plenty of water and staying in air-conditioned places might help. But ultimately, what determines survival is the presence or absence of complicating ailments like diabetes and hypertension.


There are plenty of diabetic hypertensives Filipinos out there. These people should be more cautious of their health conditions during these hot months. The risk of having cerebrovascular stroke increases in direct proportion to the increase in environmental temperature.

Things I Learned at the First Philippine Health Financing Summit

'Better late than never.

Finally, after so many years, the Philippines had its first Health Financing Summit last April 14, 2010 at the GT-Toyota Asian Center Auditorium inside the UP Diliman Campus.

It was very low-key. I don't think the media covered it. Most of the people who attended were from the academe. There were lots of familiar faces from UP Manila, Ateneo Graduate School of Business, De La Salle University, and the Asian Institute of Management.

• The likelihood of having appendicitis in a lifetime is 7 percent. At present, if one undergoes appendectomy, the total expense from the operation and hospitalization is around Php 70,000.00 or US$ 1,574.00 (1 US$ = Php 44.48) ¹.

• For Filipino women, the likelihood of having breast cancer in a lifetime is 12 percent. After being diagnosed, expenses will most likely run in the range of Php 1.5 million  or US$ 33,760.97 for the first year, and around Php 120,000.00 or US$ 2,700.88 per year for the next four years, excluding doctors' professional fees ¹.

• Latest available national health account data available is 2005. It shows a per capita health spending of P1,978 or US$ 44.52 in 2004 to P2,120 or US$ 47.72  in 2005 or a measly 7.2 percent increase ². 

• Health spending in the Philippines is mostly private or out-of-pocket.  Nearly 60 percent of all health spending here is out-of-pocket ².

• WHO defines catastrophic health spending as any of the following: [a] it happens when households reduce their basic expenditures in order to cope with paying the medical bills of one or two of their family members, [b] it may be equal or above 40% of the household's capacity to pay, and [c] there is no consensus on what the catastrophic threshold is.

• Poor families define catastrophic health spending in very simple terms: it is a choice between being unhealthy or being poorer.  

• The government response made thru  the Department of Health (DOH) to counteract out-of-pocket health spending is to increase social insurance coverage ³. It presents the framework below as for health sector reform:

• In terms of health indicators like infant and maternal mortality rates, the Philippines has shown improvement from 1950 to 2009, but lags behind when the same figures are compared with its Asian neighbors like Thailand, Malaysia, Singapore, Vietnam, Korea and Japan. It only fares better than Indonesia ⁴.

• Professor Phua Kai Hong of Singapore acknowledges that while there is substantial growth of social insurance in the Asia-Pacific region, the current predominate health spending method is still out-of-pocket. In China, for example, 50 - 60 percent of the total health budget is spent on drugs and diagnostics.

 

Slide from Prof. Phua Kai Hong, NUS

Health Systems Financing: 

Examples from the Asian Region

•  Prof. Hong also said showed the health expenditures as percentage of GDP of developed countries. "But don't be misled," he said. "It's not how much countries spend that's really important, it's about getting the expected results. The questions to ask are if people get well or if they die in spite of all the health spending."

 

Slide from Prof. Phua Kai Hong, NUS

Health Systems Financing: 

Examples from the Asian Region

•  What we can learn from the Singapore experience ---In the figure above, Prof. Hong gave reasons for Singapore's high health performance ranking in spite of its low per capita health expenditure: [a] their relatively high GNP, [b] their lower consumption due to their age structure, [c] their strong budgetary controls on public spending, [d] the absence of a comprehensive health insurance, and [e] government subsidies for public health and differential pricing for personal consumption.

• UK Ambassador Stephen Lille gave a picture of what the UK National Health Service (NHS) is. Founded in 1948, it has these 3 magnificent core principles: [a]  it meets the needs of everyone, [b] it is free at the point of delivery, and last, but most important I think is,  [c] it is based on clinical need, and not the ability to pay.

 

Slide from H.E. UK Ambassador Stephen Lille,

The UK National Health Service

• The UK Ambassador ended his talk with this quote from Aneunn Bevan, the NHS architect: "No society can call itself civilized if a sick person is denied medical aid because of lack of means." Ouch! There's the rub.

• To many Filipinos, good health has always been associated with the availability of medicines and the capacity to pay for their respective prescribed dosages made by physicians. This is sad as this shows that the current mindset still remains to be curative and not preventive. 

• Because good health = availability of medicines, the drive is to make the government go beyond the Cheaper and Quality Medicines Law, go beyond the Maximum Drug Retail Price (MDRP)  Executive Order, go beyond the Food and Drug Authority Law, and go beyond the Generic Act of 1988. MDRP should have expanded coverage and include all essential medications.  This remains to be a great challenge for the next President of the Philippines.

• There must also be a bridge between health financing and quality of care delivered. Poor quality generates additional costs and current financing arrangements may impede health improvements. 

Slide from Dr. Madeleine de Rosas-Valera, WHO-WPRO

Patient Quality and Safety: 

A Requirement for Successful Health Financing

•  Mayor Sonia Lorenzo of San Isidro, Nueva Ecija, a small town in Northern Philippines, gave a talk on how a local government unit is able to cope on health expenditure problems. She cites the value of volunteerism among citizens, the importance of integrating health in schools, allotting 16 percent of municipal funding to health concerns, and having at least 10,000 families enrolled in social insurance with member co-sharing.

Overall, my verdict on this summit is more than satisfactory. Presentations were able to identify the problems and suggest possible solutions. My only criticism is that it tried to cover so many topics in such a short time, to the detriment of the audience missing out taking their lunch. Next time, organizers should make this at least a two-day affair.

In summary, I think the main problems in health financing in the Philippines are:

1. Not enough money available - holds true for both the citizens, who spend mostly out-of-pocket for their health expenditures, and the government, which is tasked to address all health need problems.
2. Weak Political will - the next President should have a stronger will to make health a priority in his administration programs. The next Health secretary should also have strong public health leadership skills.
3. Corruption - needs to be stopped so lost money can be channeled to number 1 where it is mostly needed.
4. Preventive, Not Curative - Filipinos need to learn that in the long run, an ounce of prevention is cheaper and goes a long way than the more expensive pound of cure.

_______________
Sources: 1 - Dr. Alvin Caballes, Social Medicine Unit, UP Manila
             2 - NCSB 2005, Philippine National Health Accounts PNHA
             3 - Dr. Liezel Lagrada, DOH
             4 - Dr. Eduardo Banzon, World Bank

GRAND ROUNDS Volume 6, No. 29

After a hiatus of almost a year from hosting Grand Rounds, I am back today to welcome you all to GRAND ROUNDS, Volume 6, No. 29. This is my 6th time to host this weekly round-up of the best in med- and health blogs. If one is passionate about it, hosting can be a taxing experience. More often than not, it eats precious time one should allocate for sleeping. Thank God I live on the other side of the planet, and most of those who submitted are on the opposite side --- I can still rest tonight. 'Kidding! I am always proud to host. I thank Nick for the invitation this week. Thank you also for all those who joined.

Those who are familiar with me know I do not require themes. I think requiring bloggers to create posts revolving on a certain theme asphyxiates creativity, and makes the job easy for the assigned host only. In my case, I arrange submitted posts as they arrive, and I try my best to include everyone. I also visit and read each post submitted.

Let's begin:

CHOICE CUTS - these are the best of the best,
and as such, are must-reads.

As Oscar Wilde said, the truth is rarely pure and never simple.

Such was the problem of the #1 Dinosaur when faced with the difficulty of telling a patient the truth about the death of his wife. It was a moving experience and you can almost palpate the emotions involved.

How does a doctor encourage a patient to tell the Truth?

Ah, compassion fatigue. It happens to all of us. Even to doctors and general surgeons like Bongi. It is difficult to admit at times because no one wants to look bad in front of people and patients. But ignoring it does not make it disappear. In the place where I practice, physical exhaustion matched with loss of idealism remain to be its top cause. Read Bongi's reasons on why doctors succumb to it. 

This is a very short post by my friend Ramona Bates, M.D., who is a plastic surgeon in Little Rock, Arkansas.

Short. Sweet. Very profound.

What is the story behind your scar?

Death comes to us all, doctors and patients alike. But doctors always try to put up either a brave front or feign a deep connection with a patient to prepare themselves.

Inspired by an article from the New York Times, Pallimed explores how a palliative care physician and her relatives cope with death.

I have a few patients with Cushing's Disease, and because it is not a common disease here, it becomes quite a challenge when explaining the nature of the ailment to both the patient and the relatives. A doctor is a healer and a teacher most of the time. It comes as whiff of fresh air to me then, when librarian Laika makes a complex condition sound so simple and easy to understand.

Cushing's Disease explained in simple terms. 

USEFUL TIPS and HOW-TOs -
bloggers offer the steps on some interesting topics.

Chris Nickson points us to the great William Osler as we learn how to be a better observer. Very valuable in Medicine as doctors are also constant investigators.

A Board-certified Orthopedic surgeon guest blogs in How To Cope With Pain, and highlights the merits and details of self-hypnosis in surgery.

This is bad news for Anaesthesiologists. 

In this time of frequent earthquakes and other unexpected disasters, Jill of All Trades, MD urges us to prepare our respective emergency kits.

It is difficult to avoid patients who consult because they want narcotic prescriptions. What to do and how to get rid of them?

For the second time, Jill of All Trades, MD carefully explains to us the steps on how to 'dance' gracefully with narcotic seekers.

Finally, here's a very useful tip for medbloggers who lead double lives of being simultaneous health professionals and bloggers.

Lockup Doc teaches us how to handle medical blogs and a busy life.

POINTS TO PONDER - strong opinions on select topics

Dr. Jolie Bookspan offers a comprehensive discussion on Achilles tendon surgery, weighing on important issues like whether ligament tears can heal without surgery and whether surgery plus physical rehab, or physical rehab alone is the favorable approach.

A double fault for Martina Navratilova on her recent breast cancer diagnosis. Know if you agree with Eve Harris or not.

EverythingHealth has second (and third) thoughts on whether sexual addiction is real or not.

Tiger would? Tiger wouldn't? Take your pick.

Here's a lengthy, lengthy, lengthy post on a medical oversight case in North Carolina. Did I say it's a long post? Dr. Mary Johnson also gives us a fair warning, but do not let that discourage you. It is a strongly assertive post on the clash of medicine and the law.

Happy Hospitalist dissects the many alternatives on female hair restoration. I would have considered this a good post if only Happy removed all those subtle links to Amazon, which offers several hair restoration products.

Philip Hickey, PhD offers a number of points to prove that schizophrenia is not an illness.

NICE TO KNOW - improves your conventional wisdom

ACP Internist tells us why peace of mind is so expensive in health care.

Most males dread vasectomy. Who doesn't?

Unbounded Medicine weighs in on both the effectiveness and failures of vasectomy procedures. 

MPAA has faulty classification standards?

Find out with Nancy Brown, PhD, as she explores a probable reason why adolescents today are becoming more likely to commit violent crimes.

As a physician with an MBA degree, I found this post written by Dr. Joseph Kim useful.

MD/MBA career paths in the financial services? Would you consider this as an option?

ACP Hospitalist has good advice to give those who go out drinking alcohol with friends.

HEALTH CARE POLICIES - most of these posts discussed 

different aspects of the Obama Health Care Reform

Can health insurers "cherry-pick" patients?

Read the Cockroach Catcher's Obama and the NHS: Patients Trading.

The Health Business Blog tackles one of the main criticisms of Obama's health care reform law --- cost control.

InsureBlog says insurance rates might rise and there might be a potential shortage of physicians in the future.

Chris Langston the majority of today’s health care providers are still fundamentally incompetent in caring for older patients.

Is the glass half-full?

The Health Insurance Insider ponders on expanding coverage for people with health conditions.

Catherine Hess, Senior Program Director at the National Academy for State Health Policy (NASHP), writes in Health Reform Galaxy Blog about her desire to push for kid's enrollment in public insurance programs.





That's all folks. I now bid you good night from Manila, in the Philippines. Happy reading!

Tune in at the Sterile Eye (over in far, far Norway) next week for the next edition of Grand Rounds.

Hosting Grand Rounds Again...

Medical Grand Rounds will be hosted again here at Parallel Universes next week, April 13, 2010.

Grand Rounds is a weekly collection of the best health and medical posts made by doctors, nurses, students, patients, and others in the health-related profession.

Please submit your post links to doc.emer at gmail [dot] com on or before 11:59pm EST of April 12, 2010.

Don't forget to include a brief description of what your post is all about.

Like the veteran GruntDoc, this edition will have NO theme. I'd like to think I'm creative, but creativity will show itself once I collate all your submissions and decide how to arrange them.

Meanwhile, go and visit this week's awesome host, Dave's THE DAILY MONTHLY, which hosts this week's Grand Rounds and has an excellent collection of health posts relating to nutrition and fitness. I promise you will learn a lot there!

What Poor Filipinos Are Eating

Last January 2010, the Social Weather Station (SWS) published the results of a poll undertaken on the last quarter of 2009. This poll said that the number of Filipino families that claimed to be hungry reached 4.4 million, with 24 percent as the hunger measure. This figure was more than five points higher than at the end of September and worse than the previous record of 23.7 percent in December 2008.

Government statistics reveal that nearly 40 percent of the Philippine population can be considered poor. Additional data say that an average Filipino family composed of 6 members (father, mother, and four children) can survive using only an income of P38.00 a day. That's not even equivalent to 1 US dollar using today's foreign exchange rates.

What can P38.00 buy and what do poor Filipino families really eat?

Based on my own observations, the poor among us survive by:

• eating only ONCE a day; a worse case scenario means eating ONCE every OTHER day
• eating rice with salt alone
• eating rice with soy sauce alone
• eating rice with coffee alone
• the 'lucky ones' eat rice with instant noodles which sell around P5.00 - P9.00 per pack, and cooked diluted with plenty of water
• the so-called 'clever group' NEVER eats and opts to sniff rugby instead

If you analyze it, the poor families get a carbohydrate and salt-riddled diet which is very unhealthy and can result in chronic malnutrition in the long run.

NUTRITION FACTS on a Noodle Pack

Those mothers who care for babies are also known to give their babies not the usual pediatric milk formulas (which are very expensive), but cheaper milk brands which are either powdered or in the condensed form and like the cooked noodles diluted to a final product that is wanting in the needed vitamins and minerals a growing baby needs.

Feeding the baby: ONE NOODLE at a time