Banihal, a town on the other side of the Peer Panchal ranges of the Himalayas, is connected to the valley through a tunnel. It is a rural and hilly area, in the district Ramban of the Jammu area of the UT. The population is largely Kashmiri speaking followed by Gojree and Urdu. It has a population of about 8500. There are 33 villages in the Banihal Tehsil with an estimated population of 1.35 lacks.
Our Banihal Tehsil Activity of the GHHP was done on 19th December in the Sub-district Hospital’s new, but yet to be commissioned Trauma Centre. Banihal Volunteers organization helped immensely in coordinating the camp. It’s an NGO, whose main work is to help and carry out rescue operations in road accidents which happen frequently on this hilly national highway going to Ram ban and then to Jammu through Udhampur.
We saw 110 patients but only 82 met the inclusion criteria of our project (Established hypertension, diabetes with or without related heart problems). Our aim is to ensure treatment to targets of patients with pre-existent hypertension, diabetes and related heart diseases.
All patients besides drug treatment are counselled for life style management. All the patients registered have a complete evaluation as per a pre formed questionnaire. Measurement of body mass index, BP using a calibrated instrument, random blood sugar and serum lipid estimation by point of care instruments in diabetics. Additionally, an electrocardiogram (ECG) was taken for all by a special ECG machines capable of transmitting the high-quality tracing reported through I cloud on an App downloaded with the doctors.
Of the patients seen, all were Kashmiri speaking, 59% of them males. 39 of them (48%) were between the age groups of 40 to 65 years of age. This was same as in the other 3 districts visited till date. Socio economic conditions were poorer in this district with 45% earning less than Rs 20,000 per month as compared to an average of 26% in the other districts of the valley. They were physically much more active with 60% walking more than 30 minutes per day as compared to less than 25 to 30% in the valley districts. In spite of this overweight / obese population prevalence was similar coming to a figure of around 50%. Like thee population of valley more than 80% were consumers of salted tea (Noon Chay).
Established high blood pressure on treatment was seen in 39 patients (47%) and diabetics on treatment 12 patients (14.5%). Forty (48.5%) Patients with high BP had uncontrolled BP as assessed by us in a resting state with calibrated machines. This was higher than the figures seen in our previous camps. The sub-zero temperatures could be one of the factors. However, this observation is of significance because winter is the time when strokes and heart attacks become more frequent. Out of these 17 (35 %) had BP levels more than 160/100 mms Hg. Ten of these patients also had diabetes. Diabetes with hypertension is a bad combination resulting in high incidence of strokes and heart attacks.
There was a total of 12 diabetics (15%). Five of the 63 patients where blood sugar was done had levels more than 180 mgs%. All were known diabetics and had blood sugars more than 235 mgs/dl. Three of them had sugar levels more than 350 mgs. The treatment of all of them was optimized and newer agents like dapagliflozin added.
All the patients underwent an electrocardiogram (ECG). Forty-five (55%) had normal ECG’s. Five patients (6%) had atrial fibrillation, with an average age of 63,4 years (range 50 to 75) years of age. This arrhythmia is a predisposing factor for strokes and needs aggressive anticoagulants. None of them was on them. Instead they had been prescribed anti platelet agents (Aspirin, clopidogrel etc), which have no benefit and can cause adverse effects. All of them were given cost effective novel anti-coagulants like dabigatran which are now generic in our country and have an anti-dote also. Four patients had permanent pacemakers implanted in the past for slow heart rhythms.
One of the concerning things we noticed in the prescriptions from local doctors was that lot of unnecessary medicines are prescribed. Many of them vitamins, anti-oxidants, anti-acids and pain killers. These not only are a drain on the meagre earnings of the patients but have no benefit. Very often the ignorant patient takes only these and forgets the drugs for high BP and diabetes etc. The local population also brought this to our attention during the CME held the next day.
A public CME was held on the morning of 20th December attended by a sizeable community from Banihal, many of them from the business community and volunteers from the town. We made them aware of the numbers of high BP and diabetes patients and goals of treatment. The necessity of knowing the BP levels and sugar levels for all adults was emphasized. Treatment to targets as the need of the day so that heart attacks, strokes and kidney diseases could be prevented for a healthy community in the Tehsil so important for their upliftment in years to come.
Case Studies:
- Twenty-two years, old lady who had given birth to a healthy baby was noted to have a complex birth defect at normal delivery. The lady had a cyanotic heart disease (blue patient) with an arterial saturation of 86% with clubbed digits. Echo cardiography confirmed the diagnosis of Tetralogy of Fallot. Parents had missed the blue colour of their daughter and got her married without a medical consultation. The male child is one month old and it is now the family knows that the mother has a serious birth defects of her heart. GHHP has already organized her full evaluation through the Cardiologists of AIIMS in New Delhi within a month and family has readily agreed.
- A 3 months old baby with a serious defect of a large hole in the heart called ventricular septal defect (VSD) needs early surgery within a year otherwise she would become inoperable. This child is coming to Delhi AIIMS in First week of January 2021 and GHHP has already tied up with the head of Paediatric Cardiology department for her management.
Lessons Learnt:
In the Kashmiri population belonging to this hilly part of the District Ramban across the Peer Panchal ranges, the problem of uncontrolled BP is more than in all the 3 districts visited by us (North, Central and South Kashmir). The population is physically more active but economically poor with a need for upgrading the medical facilities. This needs the attention of health care providers on a priority. GHHP has decided to visit it at least 3 times a year to monitor the progress.
End Note:
We want to acknowledge the organizational help rendered by the Banihal Volunteers Group, Ilyas, Basit Rafiq and team. We also acknowledge the help offered by CMO Banihal for providing the venue and the pharmaceutical industry for keeping drugs available as starter kits.