Lung health: Cough is not normal

Lung Week: 12-17 November
 As the world marks the Lung Week, Citizen News Service - CNS' Kakaire Ayub Kirunda speaks to the president of the Uganda Thoracic Society Dr Martin Okot-Nwang who recently retired after several years of service at the country’s national referral hospital in Kampala. Dr Okot – Nwang speaks about the state of lung health in Uganda and resource limited settings.

Do you think lung health diseases deserve to be among issues of public health importance?
Lung health has always been a matter of public health importance. The difference between then and now is that a number of doctors decided to go beyond specialization. You find that a doctor used to be a physician and a surgeon. Today doctors are either physicians of the kidney, of the heart and so on. So this kind of thing has kind of pooled patients. Therefore the magnitude is easier to see because of this pooling and cumulativeness. Therefore the diseases have been recognized. Indeed it is not only in lung health but also other diseases like diabetes.

Could you please share with us the commonest lung health diseases that Uganda and perhaps other low income countries are grappling with?
In our case the commonest infectious lung disease is pulmonary tuberculosis. We also see quite a number of asthma cases. But we see all forms of lung conditions like Chronic Obstructed Pulmonary Disorder (COPD), Lung Cancer, pneumonia especially in children and many others. But really, the main one is tuberculosis.

What are some of the predisposing factors to these diseases that you have mentioned?
In the case of tuberculosis, we are in an environment where the disease is very prevalent. That gives rise to people being or young children being infected or acquiring the infection at the beginning of their life. Majority of people will fight off the infection but for now HIV/AIDS is the biggest risk factor. However,  many times also patients present late. And in TB we say by the time a patient presents themselves to the hospital they have passed the germs to ten people.

Coming to Asthma, the exert cause is not known. But, there are family factors at play in some cases. If the family bears a history of Asthma or Asthma related illnesses like skin eczema they are more likely to get it. There are also environmental factors like smoking, and the workplace environment.

As far as COPD is concerned, it has all along been known to be a disease of smokers but there are research evidence showing that not only cigarette smoke causing it but also indoor smoke from biomass. A number of TB patients also tend to get COPD like illnesses.

As for lung cancer, it is associated with smoking.

In what state is the diagnostics situation at the Mulago national referral hospital which attracts hundreds of patients yearly?

The basics needed to diagnose lung conditions are available. For example the basic requirement is a sputum examination and a chest x-ray. When Lung disease is suspected, those two are a must. And we have been doing bronchoscopy for over ten years now. Without that, one may not be able to diagnose something like lung cancer easily. You can see an abnormality on the x-ray but won’t be able to know what abnormality it is. So, one needs a bronchoscope to do that. As a result of a project called fresh air the hospital acquired some important equipment called a spirometer which is important for diagnosing COPD. In summary, I think we can examine sputum very well by looking for bacterium for tuberculosis, looking for cancer cells, can do x-rays, and also CT scan of the chest. Therefore, what is offered is not too rudimentary. I think it is about 70 to 80 percent of what would have been in a first class facility.

What kind of patients do you receive?

For some reason, patients come late. Indeed very late. My view on this is very philosophical. I will say that it is the way lung disease presents itself. You see, most lung diseases present themselves as a cough.

Unfortunately, interpreting cough as a sickness is very difficult. There is something called normal cough and patients will try their best to get it away either using honey or ginger or over-the-counter medicines. Cough will only be considered very serious if there is something on top of it. For example if a person develops cough and in two days there is blood in the sputum that becomes serious and they will run to hospital. If a person develops cough and after five days there is panting, they get concerned.

I have also heard experts in other areas saying patients report late. So the whole concept of health seeking behavior may be responsible for it.

Is there anything that can be done to improve on health seeking behaviours and minimizing lung disease causing situations?

When we have structures it becomes hard to do things outside the structure unless you form another structure to work with the existing one. As for me, the Ministry of Health has the responsibility to do both preventive and curative medicine. That is the structure we have. However, this does not mean that other parties should not come in. We for example have a strong anti tobacco lobby group; we now have the Uganda Thoracic Society, although just one year old. We started by writing an article in the newspapers to demystify inhalers for asthma patients. Last year one of our members gave an interview on Asthma in children.

At home we do advise proper ventilation. If you look at particularly village homes especially the huts there is where smoke can easily go out. But you also find buildings or huts where there is hardly any ventilation for free flow of the smoke.

Specifically for asthma patients, we ask them to reduce house dust, avoiding things like the carpet if they are the affluent type, to avoid strong scents, to keep themselves warm if going to be out for long periods, etc.

There is growing consensus that Community Health Workers (CHW) can be invaluable as far as improving health outcomes is concerned. Can they be of help in the context of lung health?

This is a controversial area but my answer is yes and no.  if we have a CHW that is going to be trained to spot difficult breathing, may be because a child has developed pneumonia, the CHW is going to be trained to say ‘last time I passed here this person was coughing, today they are still coughing, I think I should encourage this person to go for physical examination in a health facility’, that CHW is useful. So CHWs are useful for the purpose for which they have been trained.

However, the trouble with CHWs is that once you train one to handle one aspect and put them in the village they become basawo (health workers). So they move from handling fever to handling diarrhea. That is the biggest disadvantage of CHWs. While they may want to stick to area of competence the environment may not allow them to stick to one thing.

I think the issue of TBAs is a case in point as a spring board to put our argument. You see, when they were trained and they thought they were going to help reduce infant and maternal mortality it backfired and has never worked in any part of the world. For me if I were to suggest anything about community health work, I would not even call them CHWs, I would call them community health scouts. They would be scouting in their areas and simply advice whoever has the symptoms to go where there are trained health workers.

What are your last thoughts on lung health?

Let us stop taking cough as a normal thing. Let us take cough as a sign of serious illness and we seek appropriate treatment very early. Reduce on or stop alcohol consumption because it is not good for lung health. Quit smoking and if you don’t smoke, never think of doing it. And if you can have a house, it should be ventilated properly and the indoor smoke can move out easily. Governments also need to do something about vehicles with poor fuel combustion. Studies have observed a high prevalence of asthma cases in areas with heavy vehicle traffic in three African countries.

Kakaire Ayub Kirunda - CNS
(The author is a senior journalist from Uganda and has written consistently on health issues over years. He also writes for Citizen News Service - CNS and is CNS' Health Fellow for the year 2012)

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