Wednesday, September 1, 1999

Adolescent girls, take care!
By Dr Sarla Malhotra
Adolescence is a phase of transition in life ranging from 10 to 19 years. During this phase, there is not only progression of secondary sex characteristics to sexual and reproductive maturity but there is development of the adult mental process too. These adolescents comprise 1/5 of the world population and their number is increasing.

Not your lifestyle
By Dr R. J. Dash
The syndrome of unwanted hair on the face, the chest and the abdomen, and irregular menstruation, are often caused by polycystic ovary. In married women, this is a leading cause of inability to conceive.

Mind of the young
By Dr Savita Malhotra
Child and adolescent psychiatry, as it is practised in the USA and several West European or eastern developed countries, as an independent and highly specialised discipline depending heavily on the highly trained man power, appears like a distant dream and luxury to countries which, unfortunately, are less developed or poor. Children and adolescents living in the so-called "First World" and "Third World", share their dreams and ambitions, as well as, needs and aspirations, but they live in total contrast so far as their realities and circumstances of life are concerned.

Defence: need for research
By Dr S. K. Jindal

There is a vast network of establishments engaged in research and development of defence needs of the country. The main focus of defence research has always been on the development of machines and equipment required by the Army. The man behind the machine has not attracted many research workers or other inputs. There may have been an occasional medical project undertaken or financed by defence organisations. But the overall provision has been negligible.

Undoubtedly, there is an efficient medical wing in the Army which caters to the medical needs of the defence personnel and their families. But there is a great infrastructural paucity. One should be able to conduct research in the defence problems of soldiers and develop new models of medical service.

Any illness, which inflicts a civilian, can also inflict a soldier. There already exist a large number of centres and institutions aimed at conducting research into the general health problems and illnesses. But there are many other problems and issues which concern only the Army or, for that matter, the Air Force and the Navy. These are the problems which are owned by none and, therefore, ignored. Someone must adopt these orphan issues.

Adaptation and acclimatisation are the two major areas of concern. The defence personnel, who have to work in alien and often hostile surroundings on the hills, in deserts and forests or under the sea, are not naturally equipped to live in such areas.

Those who are posted in these locations do learn to live and adapt themselves with the passage of time. Problems arise when the time available is short. It is for this purpose that we need to work on simulated conditions and their effects on physical and psychological functions of human beings.

High-altitude problems top the list in spite of the fact that the maximum work has been done in only this area. I am quite aware of the pioneering work on pulmonary oedema which emanated after the India-China war of 1962 when a large number of Indian soldiers developed the problem arousing interest in this field. The work had won wide acclaim and helped introduce the policy of slow acclimatisation of soldiers before lifting them to very high altitudes.

In the recent past, we had seen some work in our Institute on a sub-acute type of mountain sickness never described previously. It involved a state of fluid and salt retention causing heart enlargement and excessive fluid collection in different body cavities in soldiers staying at the Siachen glacier. This was also taken care of by slow ascent and limiting the period of stay at those heights.

But that much is not adequate.

A lot more is required on the principles of oxygen physiology and therapy. Severe cold and hypoxia of high altitude induce subtle changes in the functioning of different organ systems, including the brain. It is well known that these affect mental functions and the decision-making behaviour. No one can accept the dulled decisions critical in an Army operation.

Unfortunately, any minimal blunting of reasoning and decision-making is neither detectable nor assessable. It may cause great harm to the individual and the operation. Who knows?

Oxygen, being the core of cerebro and cardio-respiratory efficiency, is perhaps the key issue which deserves a comprehensive and multi-faceted analysis for defence purposes. The blood oxygen content depends upon atmospheric pressure. Therefore, it assumes significance for not only the soldiers at high altitudes but also for those in the Air Force who fly in fighter planes at much greater heights and for the Navy men who work below sea level under high atmospheric pressures. A lot is known about its physiology in Aviation and Deep-sea Medicine. But we have to develop our own scientific database to handle our problems. To the best of my knowledge, we do not have even the standardised normograms for the cardiopulmonary and other organ function indices for the people working high in the atmosphere or deep in the seas.

While talking of oxygen, hyperbaric oxygen therapy is another subject which needs investigation. Hyperbaric conditions imply the administration of oxygen at an atmospheric pressure of greater than one. Such treatment has been used for a variety of medical and surgical illnesses. The Indian Navy has got a unit under its aegis. The widened scope of the subject is certainly stimulating for many workers in this field.

Trauma, resuscitation, physical and mental disability — and rehabilitation — are the obvious concerns which bother the defence establishments most. Presumably, enough is being done although even enough is not enough in critical areas. There is always scope for introducing more innovative ideas and interventions.

The list, by no means, is comprehensive and can be expanded to include many other specific and general issues. The basic point, however, is the need to recognise the urgency and importance of medical research in Defence. The post-Kargil trauma should help us in realising and removing the lacunae.

The writer is the Additional Professor and Head of the Department of Pulmonary Medicine at the PGI, Chandigarh.

Adolescent girls, take care!
By Dr Sarla Malhotra

Adolescence is a phase of transition in life ranging from 10 to 19 years. During this phase, there is not only progression of secondary sex characteristics to sexual and reproductive maturity but there is development of the adult mental process too. These adolescents comprise 1/5 of the world population and their number is increasing.

Having survived infancy and childhood diseases, they are the healthiest section of society but as they mature and become sexually active they face serious health risks.

These risks are more pronounced in girls because of complications of pregnancy, delivery, unsafe abortions with unintended pregnancy and risks of sexually transmitted diseases including HIV infection. About 5,00,000 mothers are dying every year the world over as a result of the complications of pregnancy and delivery, amounting to one maternal death per minute. About 98-99 per cent of these deaths occur in the developing countries. These mothers are born as undervalued and neglected girls and grow up as exploited, uneducated adolescents.

As infants, they have a greater infant mortality rate. The protein energy malnutrition is five times higher in female infants as compared to male infants.

They get less food to eat and are supposed to eat after their father and brothers have eaten. They have little or no access to school. The dropout rate (from school) in fortunate cases is high. Not only this; today they are eliminated even before birth, leading to a dangerous tilt in the sex ratio which, according to the 1991 census in the City Beautiful, is 790 females to 1000 males.

The girls enter reproductive maturity with all the discriminations — with poor reserves in their bodies, anaemia, short stature and small pelvis to take on the heavy burden of child-bearing and unintended pregnancy.

A large number of adolescent girls are pushed into reproductive life because of early marriage. About 44 per cent of the girls are married in India between 15-19 years, 34 per cent are married in Nepal at less than 15 years of age. Another segment of adolescents enters into sexual activity because of premarital sex or sexual violence. Whatever may be the reason, once pregnant or sexually active, maternal mortality is two to five times higher in teenage girls. STDs and HIV infection are much higher in adolescent girls.

The highest incidence of gonorrhoea is found in sexually active adolescent girls in the USA. Up to six million people infected with HIV are less than 25 years old. We, as medical professionals, teachers, parents and society, cannot be silent spectators to such appallingly high but preventable mortality and morbidity in these young mothers.

Nurturing girls is the key to investing in women's health. We have to change our attitude and learn to value the girls who are going to be future mothers. We have to look after their nutrition and supplement iron for their monthly blood loss. We have to pledge not to do and not to be a party to the termination of pregnancy (for female sex reasons). We have to provide caring, confidential and non-judgmental advice to adolescents. We also have to understand adolescent sexuality with a flexible attitude.

We have to impart family-life education, including sex education, to our children for which both teachers and parents have to share the responsibility equally. The quantum of help needed by adolescents girls to avoid health risks varies. Those who are not sexually active need support and skill to postpone starting sex and those who suffer from sexual abuse need protection and care. Those who are sexually active because of early marriage or other reasons need advice to abstain from sex and use condoms. They need ante-natal care when they are pregnant.

Last but not the least, we have to reach out to adolescent boys to address the health and social issues of adolescent girls, who have largely been left off the hook. The need to educate them in their responsibility towards girls is tremendous. Adolescents need access to medical services related to reproductive health at a time and place convenient to them by caring and sympathetic personnel who understand their needs and peer pressure.

The writer is the Professor and Head of the Department of Obstetrics and Gynaecology at the Government Medical College and Hospital, Chandigarh.

Not your lifestyle
By Dr R. J. Dash

The syndrome of unwanted hair on the face, the chest and the abdomen, and irregular menstruation, are often caused by polycystic ovary. In married women, this is a leading cause of inability to conceive.

The unwanted hair and irregular menses in marriageable girls are the concerns of the parents in their search for suitable boys.

The term polycystic ovary is a misnomer as the ovaries do not contain tiny bags of fluids. The so-called cysts are atretic follicles resulting from follicles that have failed to produce eggs.

These atretic follicles produce an excess of androgenic steroids or male hormones that stimulate the growth of facial, chest and abdominal hair, disfiguring acnes on the face, inducing menstrual irregularities and ending up in the cessation of the menses (amenorrhoea).

The excess of androgenic steroids is converted into oestrogen in the liver and fat cells that maintain high pituitary gonadotropin (LH) secretion and, through it, an excess of androgen production from the atretic follicles. The ovaries are usually large and the involvement is bilateral.

The cause of polycystic ovary ( or ovaries) is a matter of debate. Since the disease may run in families, some consider it genetic. As the pituitary LH is the driving force, some look for its cause in the coordinated activity of the brain, the hypothalamus and the pituitary gland. Most people, however, consider this an environmental insult initiated in the peripubertal age by an excess gain in weight. With love for fast food, apathy to physical activity (thanks to the two-wheeler and small-car craze and one's liking for cable TV) the incidence of obesity in peripubertal girls is high both in urban and semi-urban populations. The Green and White Revolutions are contributing together to this environmental influence.

Once initiated, the vicious cycle of excessive ovarian androgen production, peripheral androgens to oestrogen conversion, an increase in pituitary LH drive and more atresia of the follicles continues. This problem of adolescence continues through the adult years.

In the adult females, the process may begin with the first child-birth when the proud mothers, happy with their achievement, turn to foods with higher nutritious values, and lesser physical activity, with a rapid gain in weight.

With early repeat pregnancies and continued weight-gain, the process similar to that in adolescence, is initiated, resulting in full-blown manifestations of polycystic ovary.

An ultrasound of the ovaries and the quantitation of the pituitary gonadotropins, LH, FSH and androgens a few days after the onset of the menses are needed for making an accurate diagnosis. Polycystic disease is also seen in normal and underweight girls doing strenuous exercise.

The treatment of polystic disease is guided by certain principles. In young unmarried girls, the emphasis should be given to weight-management through diet control and increase in physical activity. Where unwanted hair growth is socially unacceptable and frequent visits to beauty parlours become a necessity, anti-androgens alone or in combination with oral contraceptives are prescribed. Drugs are needed to functionally knock off the ovaries to produce androgenic steroids, block the effect of androgens at the hair roots and sebacious glands beneath the skin.

The dose of androgen-blocking drugs is variable to the patients' need and response. Once the vicious cycle is broken, oral contraceptive steroids can be withdrawn.

In married women, debulking operations or lesser treatments are sometimes advised to physically reduce the size of the ovaries and the production of androgens. Drugs for the induction of ovulation are given for the treatment of infertility under demanding circumstances.

Preventive measures at weight gain is a basic requirement. Seeking right advice from specialist physicians for investigations and management is obligatory. This is particularly important as about one third of normally menstruating women may have polycystic ovary on ultrasound.

The author is the head of the Department of Endocrinology at the PGI, Chandigarh. He is the seniormost Professor in his discipline in the country.

Mind of the young
By Dr Savita Malhotra

Child and adolescent psychiatry, as it is practised in the USA and several West European or eastern developed countries, as an independent and highly specialised discipline depending heavily on the highly trained man power, appears like a distant dream and luxury to countries which, unfortunately, are less developed or poor. Children and adolescents living in the so-called "First World" and "Third World", share their dreams and ambitions, as well as, needs and aspirations, but they live in total contrast so far as their realities and circumstances of life are concerned.

Child ( infants and adolescents included) psychiatrists do not endeavour to directly change the realities of life for children but certainly aim at recognising the needs and aspirations, potentials and limitations of children. The best ways are found to realise these and to bring these to the attention of society which, in turn, is expected to make significant changes in the psycho-social and physical environment of children.

There is now sufficient research evidence to show that the application of the principles and practice of child psychiatry makes a significant positive contribution to the lives of children in terms of reducing morbidity, ameliorating dysfunction and distress, and supporting normal development. The question is how to apply this knowledge and the skills to the vast majority of children living in developing countries like India. Since there are very few professionals to deal with the situation, the solutions would lie in looking for alternatives.

Being an Indian, I would like to speak with reference to India. The evaluation of several health-related programmes and policies that came into operation since India became independent indicates that here we have recognised the importance of pre,peri and post-natal as well as infancy periods of life. There are several programmes that target maternal health and nutrition during the ante-natal period, safe delivery, immunisation in infancy, the prevention of communicable diseases in order to reduce peri-natal and infant mortality and prevent certain acquired diseases.

The Integrated Child Development Scheme (ICDS) (started in 1975), provides additionally for non-formal education to children up to six years of age and has covered approximately 70 per cent children in the country. These programmes have succeeded in lowering the infant mortality rate significantly and the gross morbidity rate to some extent.

The period of childhood (6 to 12 years) and adolescence (12 to 18 years) is relatively neglected in terms of special attention or programmes as if all is well and assured for a child who survives the first five years of life. As we know that appropriate and timely intervention can make a difference to the outcome of pregnancy and childbirth, in the same manner, an appropriate and timely intervention strategy in childhood can make a difference to the adult outcome.

The child develops in a microcosm of his (gender used generally) gene pool, which is in constant and reciprocal interaction with his macrocosm of the environment including the physical as well as psychosocial surroundings. The family, the school and other social institutions exercise a significant influence on the process of child development.

Child development is to be seen as a continuous process until adulthood, and childhood is to be seen as a period of transition and vulnerability. The quality of childhood one has lived will determine the ultimate nature of adulthood.

If the stage of the best and the maximum productivity is the flashpoint of adulthood, childhood is a period of preparation and shaping into that stage.

In India, child mental health has been paid less attention than it deserves owing to several reasons. Apart from the fact that children have no political voice or power, they are unproductive members of society. They are a responsibility of their parents. It is also the lack of knowledge about what mental health intervention can do or achieve that is responsible for the neglect or the low priority accorded to child psychiatry. Children are neglected for being children today, least realising that they are the adults of tomorrow. We need to look after children today for shaping a better tomorrow.

Child mental health, in this context, will have to be seen as a discipline that can influence the mental health states of adults through the possibilities of early intervention and prevention of mental disorders continuing into adulthood. Recent research has increasingly shown that childhood psychiatric disorders and developmental disorders continue into adulthood throwing up significant morbidity.

Adult general psychiatrists do need to know about the continuity of childhood disorders in later adult life and the roots of many adult psychiatric disorders lie in childhood.

Our current state of knowledge of biological, social, psychological and environmental factors that influence the psychological development of children, if applied appropriately and adequately in practice, can bring about a significant reduction in morbidity. Thus child psychiatry can be considered preventive psychiatry for adults. If we accept the life span approach as the defining dimension, child psychiatry can even be termed alternatively as developmental psychiatry.

The argument for the prevention of illnesses in adults can be more effective with politicians and planners than the argument for the care of children for their sake. Perhaps, in the present era where economic productivity and cost-benefit ratios, are considered more relevant in guiding the allocation of resources, child psychiatry needs to be similarly packaged in alternative terminology for becoming effective in attracting attention and resources. My intention, therefore, is to highlight those aspects of child psychiatry that deal with the prevention of morbidity and the promotion of positive growth into adulthood for at least a country like India.

Child psychiatry should be integrated into, and form a major proportion of the curriculum for MD psychiatry and MD paediatrics. Intervention strategies should involve and look upon parents as a very important resource and allies in the ongoing treatment. It is time to shift the focus from parents being construed as the cause or contributors of pathology to them being helpful, concerned and committed resources in therapy. This is particularly relevant to Indian culture and tradition where a strong family system will exists and exerts a powerful influence on the development of children. Let child psychiatry in countries like India move out of "specialised clinics" to the homes and families where children live.

Dr Savita Malhotra is the Additional Professor of Psychiatry at the PGI, Chandigarh