Banihal in Kashmiri language also means blizzard (A heavy snow storm with gusty winds). Another view regarding the origin of the name of the place is that the word ‘Banihal’ has actually been derived from two Kashmiri words viz ‘bah’ meaning twelve and ‘nallhe’ meaning a rivulet. Twelve rivulets signifying the various brooks flowing through the area and eventually joining the small local river called Nalla Bischlari. In Persian Nihal means ever green. Whatever way it is interpreted it gives an idea what the place is- Snow, Winds, rivers and Green.
It is a rural and hilly area surrounded by spectacular hills. The population is largely Kashmiri speaking followed by Urdu and Gogri speaking population. It has a population of about 6500 persons with a high literacy rate of around 85%, which is more than the national literacy rate. There are 33 villages in the Banihal Tehsil with an estimated population of 1.35 lacks. Total area of Banihal Tehsil is 563 km² including 559.01 km² rural area and 4.07 km² urban area.
Our team plans to arrive on 18th afternoon with all the arrangements for the camp from Srinagar in terms of machines and test kits etc. The location of the GHHP camp will be the new Government Hospital. Dr Rabia BMO will be overlooking the arrangements. More than 100 patients have already been selected by the district health authorities. They are from besides Banihal town from Dolegam, Mangot, Neel , Maho and Pogal. The approximate population of these areas adds to around 50,000 as per current estimates. As per the country’s prevalence for rural and semi urban areas, the number of patients with high BP and diabetes should be 15,000 and 5,000. Like wise it is expected to have 5000 patients with established heart diseases. Since the patients coming to us will be already on treatment, it would be useful to see the level of their BP and sugar control. This would be done by on spot measurements done reliably with well calibrated instruments. In winter months because of cold and inactivity it is a common observation that the control is unsatisfactory. Our endeavour will be to review management of these patients. All of them would be evaluated by a standardised protocol consisting of BP measurement, measurement of their body mass index (an index of obesity), measurement of serum lipid profile and a full electrocardiogram.
Some of the priorities in the treatment will be prescribing combination tablets for BP control. These tablets can contain up to 3 medicines. Majority of our hypertensive population needs 2 drug combination. The most effective combination is an angiotensin converting enzyme (ACE) inhibitor (enalapril, ramipril, lisinopril etc) or angiotensin receptor blockers (ARB) (Losartan, Telmisartan, Olmesartan) with Calcium channel blockers (Amlodipine, Cilnidipine and Barnidipine). Combining Enalapril / ramipril with amlodipine is the most time tested and effective combination. It has very important kidney preserving properties especially in diabetics. The coexistence of diabetes and high BP is common in our population and is also called the “Deadly Duo”. It predisposes several folds to heart attacks, strokes and kidney failure. Combinations of ARB’s and other calcium blockers like cilnidipine also should achieve same but higher doses are needed to optimize the BP and are relatively more expensive. Some side effects like cough which are usually minor are slightly more prevalent with ACE inhibitors but do not justify widespread use of combinations with ARB’s. Single tablets have the advantage of ease of administration which is so important for a long term usually life long therapy.
Patients whose BP does not come under control with 2 drugs even in higher doses, need a third drug. This is usually a water pill (diuretic). Diuretic addition is a very useful adjunct especially in high salt taking Kashmiri population. More than 90% population with high BP can be controlled with 2 or 3 drugs in one tablet combination, under care of a district level general physician. Those who still do not respond well need a specialist’s intervention.
One of the important measures which is not practiced by our doctors is counselling the patients with improving life style. This consists of asking them to reduce salt intake, regular intake of plenty of fruits and fresh vegetables, exercise in any form daily and avoidance of smoking and alcohol. These measures can reduce by 20/10 mms Hg without a drug.
BP targets also need to be explained to patients. In any case it should be less than 140/90 at all ages but it is desirable to bring to around 130/80 mms Hg. Going below 120/80 can be harmful. Self-home monitoring of BP at home by easily available calibrated machines is the best way. It also allows BP measurement of other family members. Remember High BP and diabetes runs in families and early detection is always better.
Likewise, the sugar control for diabetics is important. A random sugar should be less than 180 mgs/dl. It is important to get a periodic (3 to 6 monthly) glycosylated Hb (HBA1c) done and the value should be 7% or lower.
One of our aims besides getting an adequate BP and sugar control is to add new drugs in diabetics to minimize the chances of heart failure and preventing kidney damage. For this drug of the group of Sodium-glucose co-transporter-2 (SGLT2) inhibitor is essential. These agents (dapagliflozin, empagliflozin and canagliflozin) are available. Dapagliflozin has become generic and costs have come down substantially. These agents should be promoted for their long-term benefit of improving the outcomes. Additionally, these agents reduce BP and weight which is often a very good addition in diabetics.
We are also evaluating the serum lipids of the patients in the form of a post meal profile. LDL cholesterol beyond 100 and triglycerides more than 200 mgs are high and need to be kept lower. In diabetics and patients with previous heart attacks or in those with blocked arteries needing stenting or bypass surgery it should be much lower. At least less than 70 preferably below 55 mgs/dl. Statin group of drugs (Atorvastatin and Rosuvastatin) is a boon for them. Both have different doses but atorvastatin is significantly cheaper. All diabetics and patients with heart disease need them under medical supervision.
On the morning of the Healthy Heart project camp, we plan a CME with all the doctors of the area and have a symposium on “Hypertension and Diabetes- How to optimize treatment”. This would be in the form of a panel discussion following a didactic talk.
We do hope the efforts of GHHP would bring in better and cost-effective treatment modalities to the population of the Tehsil and the population will be counselled to become healthier, avoid or postpones heart attacks, strokes, kidney disease and eventually improve survival. Remember healthy community leads to a healthy and prosperous nation.
Prof Upendra Kaul, a Renowned Cardiologist, is Founder Director GHHP. Recipient of Padma Shri and Dr B C Roy Award