TUBERCULOSIS IS CURABLE

Robert Koch who showed the world that TB is not a scourge, curse or god's punishment but a bacterial disease.His discovery of the anthrax bacillus as a cause of a disease in animals and the fact that it could spread from animal to man made him famous. Koch's postulates are still considered as gospel in microbiology. In 1882 he got interested in the tubercle bacillus and in 1882 he published an article on the subject. In 1883 he discovered that Vibrio bacillus caused cholera.

His discoveries on tuberculin, Rinderpest, Trypanosomiasis and Babesia are world famous. He was awarded with Nobel Prize in Physiology.

Rethink the dangers


A big problem in TB management is completion of the treatment. Once the treatment begins, the symptoms start disappearing and the patient feels normal and thinks there is no need to continue the treatment.

But the symptoms disappear because the bacillary population comes down. But some with the potential to carry the disease are still there. Similarly once the treatment is stopped the disease will relapse.

The main reason why people do not complete the treatment is because they do not like to travel long distances for the sake of drugs although they have been told that this can cause a relapse. TB sufferers who stop halfway through their course may not react positively to subsequent treatment and could be passing their own death sentences. This is where the DOTS is useful. This involves or puts the onus on the doctor or the organisation to see that the patient completes the treatment.

The government of the affected countries should put more funds into combating TB. More commitment is also required in terms of human resources — health workers, the frontline staff who deliver the DOTS strategy, are the key players.

Challenge ahead

We also need to bring together more partners, stakeholders, NGOs, community organisations that could help in the fight against TB. TB control is not anymore a government responsibility; it's a responsibility of all the stakeholders in the country.

Lastly, we know the causes and the symptoms of the disease. We know which drugs to give; what are the best regimens but we are still far from controlling this eminently curable disease.

The challenge now is to see that the government, patients, people and NGOs work together to bring this disease down. Joint action by healthcare workers and the general public is essential if the TB-monster is to be laid to rest.

Symptoms

# Unexplained fever for more than three weeks

# Cough

# Breathlessness

# Blood stained sputum

# Unexplained weight loss

# Loss of appetite

Diagnosis

# A sputum examination for TB bacilli

# A chest X Ray

HOW TO REVERSE VIOLENT INCIDENTS IN SCHOOLS ?

NEWS about school-related violence, be it vandalism or violent death have been coming in from various parts of the country with alarming regularity. It is vital to look at the risk factors contributing to violence and discuss preventive strategies.

Risk factors

Partiality and Victimisation: Some teachers classify their students into `good', `average' and `bad'. Blatant partiality towards `good' students causes frustration and anger in others. The `bad' students are often victimised for any anonymous acts of indiscipline. The labels stick. One student of std. VIII resolved to shed his `bad' label in the next year. But to his dismay, he found that his previous class teacher had taken the trouble of briefing his new class teacher.

Exposure to violence: Exposure to violence both off and on the screen can breed violence. Students exposed to domestic violence either as a victim or as an observer are more prone to violence. Corporal punishment by teachers conveys the message that it is legitimate to hit someone if they make a mistake. When the student feels that another student has erred, he will resort to violence. Media also has a significant influence on youth behaviour. The incidence of suicide climbed in Germany following a TV series about the various modes of suicide. Glorification of violence in movies and TV programmes like WWF entice students to mimic the violent behaviour.

Being teased /bullied: Students who are victims of bullying could become violent in an act of revenge. In most firearm incidences in U.S. schools, it is a victim of bullying who pulled the trigger. In India, firearms are controlled and thankfully, such incidences are negligible. But it is worth remembering that victims of bullying are emotional landmines.

Learning as a burden: School and parents put undue pressure on students to deliver marks in the board exams. This is epitomised by certain residential schools, which have a daily schedule from 5.00 a.m. to midnight. Some children burn out. Some score high marks but at a tremendous emotional cost. One `successful' student asked, "Is there a medicine to forget whatever I went through in the last three years?"

Prevention

Two main strategies would help in preventing violence. First is reduction or rectification of risk factors. Second is promotion of protective factors. Protective factors not only protect but also act as a buffer in the presence of risk factors.

A confiding relationship: This relationship has to be nurtured by the parents by listening to the child whenever he/she has something to say. By actively listening and offering comments, the parent encourages the child to communicate with ease. A student in a confiding relationship is able to discuss any issue, including frustration, sadness and anger with parents. Counsellors and empathetic teachers can fulfil this role at school. Every school should have trained counsellors. Minor issues can be sorted out early, before they intensify.

Unconditional positive regard: To nurture a sense of belonging to the family, parents need to show unconditional positive regard to their children. They should express love to their children for what they are. Conditional love ("You are my son only if you come within the first five ranks" and assorted variants of the same message) wrecks a child's sense of belonging and self-esteem. A teacher who expresses unconditional positive regard evokes positive behaviour and interest in students than one who relies on threats and punishments. For example, class XI A in one school was notorious for being `unruly and unmanageable'. A new teacher joined the school and gradually Class XI A was seen to be quiet and well behaved during his period. By the time they reached Class XII, the class was quoted as a role model.

Self Esteem: High self esteem guards against violence, emotional problems and suicide. A student's self esteem can be improved by unconditional positive regard by one significant adult (parents /teachers) and encouragement and opportunity to excel in some area. Every student should be recognised for his/her unique strength in whichever area he/she chose to focus on. It need not be restricted to academics alone. It could be sports, music, arts, writing, anything.

School connectedness: This implies a sense of belonging to the school. It gives the students part of their identity and improves their self-esteem. The student's perception that a teacher is impartial and fair, is caring and compassionate, is available and shows love to all students unconditionally helps in shaping the student's sense of belonging to the school. Parents should also have a sense of belonging to the school. PTA meetings in the true sense can foster this. Most schools have sham PTA meetings where parents are expected to meet individual teachers to discuss the marks scored in the recent tests.

Coping skills: Participation in sports and extra curricular activities help in improving one's coping skills and guards against emotional problems and violence. Coping skills can also be taught.

Conflict resolution and anger management: Conflicts are a natural part of life and occur in schools too. At times, minor conflicts between students lead to violence. Students can be trained in alternate ways of resolving conflicts like negotiation and mediation. Students can also be trained in channelising anger in socially appropriate ways.

The curriculum has provisions to impart these skills. But, in most schools this time is stolen for other `important' subjects. In one school, the Physics teacher walked into a value education class for std. XI students. "Here is a summary of your value education sessions for the next two years." He paused and said dramatically, "Be good" and then announced, "From now on, Value education periods will be Physics periods".

Joy of learning: Schools should provide an atmosphere where learning a new concept or learning a new way of doing a particular task brings joy.

Parents too should ensure that their children enjoy learning. Once learning becomes a joyful activity, students would look forward to being in school and their sense of belonging would be high. Their vulnerability to violence would come down.

SUNSHINE AN IMPORTANT SOURCE OF VITAMIN D

AS the evolution of vertebrates began 400 million years ago, a stable internal phosphate pool became necessary for mineralisation. Calcium was available to primitive unicellular organisms from their immediate environment. When multicellular organisms evolved and started moving away from the seas, a strong and mobile internal skeleton was necessary. Parathormone (PTH) and vitamin D became the principal hormones of vertebrate evolution that regulated extra-cellular calcium and phosphorous homeostasis.

Vitamin D is a fat-soluble vitamin made by our body after exposure to ultraviolet (UV-B) rays from the sun, but is also found in food. Exposure to sunlight is an important source of vitamin D. UV-B rays from sunlight trigger vitamin D synthesis in the skin. Season, latitude, time of day, cloud cover, smog and sunscreens affect UV-ray exposure.

It is important for individuals with limited exposure to the sun to include good sources of vitamin D in their diet. Vitamin D exists in several forms, each with a different activity. Vitamin D promotes bone mineralisation in concert with a number of other vitamins, minerals, and hormones.

Dietary sources

Dietary sources of vitamin D are cod liver oil, cooked salmon, eel and mackerel, sardines, liver, beef, whole egg (vitamin D is present in the yolk), milk and its products and drumstick leaves.

Fortified foods are the major dietary sources of vitamin D. Milk in the United States is fortified with 10 micrograms (400 IU) of vitamin D per quart. One cup of vitamin D fortified milk supplies about one-fourth of the estimated daily need for adults.

Although milk is fortified with vitamin D, dairy products made from milk such as cheese, yogurt, and ice cream are generally not fortified with vitamin D.

Vitamin D, calcium and phosphorus are critical for building of bone. Insufficient intake of vitamin D is associated with an increased risk of fractures. Vitamin D deficiency causes rickets in children and osteomalacia in adults.

Osteoporosis, a disease characterised by fragile bones, results in increased risk of fractures. Post-menopausal women and the elderly are at risk of developing osteoporosis. Normal storage levels of vitamin D in the body may help prevent osteoporosis.

Normal bone is constantly being remodelled. During menopause, the balance between these two systems is upset, resulting in more bone being broken down (resorbed) than rebuilt.

Vitamin D deficiency occurs more often in post-menopausal women and elderly. Adequate supplements of vitamin D may reduce the risk of osteoporotic fractures in elderly subjects with low blood levels of vitamin D.

Health impact

Laboratory studies have shown that low vitamin D intake results in increased risks of prostate, breast, colon, and other cancers. Vitamin D keeps cancer cells from growing and dividing.

Well-designed clinical trials need to be conducted to determine whether vitamin D is protective against some cancers. Vitamin D has been implicated in hypertension and skin diseases like psoriasis. Corticosteroid may also impair vitamin D metabolism, further contributing to the loss of bone and development of osteoporosis associated with steroid medications. Individuals on chronic steroid therapy should seek medical advice about the need to increase vitamin D intake through diet and/or dietary supplements.


Serum 25(OH)D levels are the most reliable indicator of the vitamin D status of an individual. Since vitamin D levels are subject to variations in diet, dress code, latitude and altitude of residence, skin colour, climate etc., the normative data varies between laboratories. These genuine geographic variations in calcium homeostasis restrict the locally estimated reference range used across the countries. Thus, locally developed "population-based reference values" (derived variously from blood donors etc.) cannot be applied globally as these values are limited by other factors.

A "functional health-based reference value" which physiologically defines hypovitaminosis D (vitamin D insufficiency) as the concentration of 25(OH)D at which PTH begins to increase is largely replacing the hitherto used "population-based reference values". This classification encompasses the "vitamin D-calcium-PTH axis" and its impact on the bone. It is more apt, and based on scientific reasoning.

Vitamin D deficiency (25(OH)D levels {lt}10 ng/ml) denote a biochemical, radiological or histological abnormality as a consequence of low vitamin D status. Hypovitaminosis D (10-20 ng/ml) is defined as a low concentration of serum 25(OH)D that indicates risk of developing vitamin D deficiency. While osseous signs often diagnose severe vitamin D deficiency, biochemical abnormalities reflect the cause and effect of vitamin D deficiency.

Low vitamin D status has far-reaching implications in diseases like fluorosis where the morbidity produced due to bone deformities is severe. It can have an impact in including vitamin D as an integral part of therapy in those vitamin D deficient postmenopausal women with osteoporosis.

Scientific organisations and apex policy forming bodies should undertake multicentric studies to develop nationally relevant guidelines. It is necessary to assess and address the issue of vitamin D status in various parts of the country where the sunshine, season, dietary habits, dress code etc, vary widely.