Smoking

The Indian Evidence on Tobacco Hazards

“Absence of evidence is not an evidence of absence” is a dictum which any rational individual always need to keep in mind. Presumably therefore, the absence of Indian evidence against tobacco hazards does not imply that the Indians are likely to behave differently than people anywhere in the world. We all know that the colour of blood of all human beings is red irrespective of their being blacks or white, or for that matter, Indians or Americans. Similarities aside, the fact remains that there is no dearth of Indian evidence on tobacco related harms. Obviously, the recent Parliamentary Committee Report on the subject is an act of short sightedness.

It seems that the Committee has conveniently decided to overlook the bulk of reports and research publications on the subject which have accumulated in the last few decades. The writer of this article himself has been engaged in clinical work on tobacco related disease since 1970s. One of my first paper which was published in 1982 in the international journal Thorax clearly showed relationship of lung cancer with tobacco smoking. The relative risk for smoking was reported as about three times more than in non-smokers. Similarly, higher risks were reported in the publications from Mumbai for several different types of cancers.

Cancer Registry Reports from India have regularly appeared which clearly show a significant relationship of cancers with both cigarettes and bidis. Most significant are the important Reports published by the Ministry of Health and Family welfare, Government of India which summarize the Indian evidence. A 2008 Report “Bidi Smoking and Public Health” was entirely devoted to bidi smoking. Only god can help if we continue to harp on the “lack of evidence’.

It is important here to understand that the cause and effect relationship in medicine is established on basis of multiple studies which are necessarily not possible to undertake in experimental laboratories. It is different from the experiments conducted in basic science laboratories. For causal relationship of diseases, one has to rely heavily on clinical and epidemiological data. Factually, these two types of studies constitute the core of medical research which represents factual relationships. From public-health view-point, it is more important to demonstrate clinical and epidemiological relationships with risk-factors than the experimental relationships. In any case, there are enough analytical studies and biochemical laboratories to show the presence of a large number of cancer-producing chemical in tobacco and their cancer-producing effects on experimental animals.

While Indian evidence on tobacco hazards including the cancers is substantial, there is far greater evidence from the American and the European continents. I must lay stress on the fact that factual information on disease causation is quite universal. It is quite true that there may be small differences in disease relationship in different countries. Some of the clinical risks and disease manifestations may vary depending upon local cultural, socio political and economic factors. But the basis facts in science remain the same. Why only cancer? This is also true for other diseases like asthma, hypertension,  diabetes and everything else. Factually speaking scientific research is universal in its application. We must not trivialize the issues by limiting the scope of research findings to a particular region on a country. We must also remember that we heavily rely on the Western data for most of cancer related research including on its diagnosis and treatment. It is irrelevant that the International companies have their own motives. That they have. But we also need to keep the health interests of the Indian people in our minds.

Cancer is not just one disease- it is a general terms for a large number of different diseases with similar a characteristic of relentless progression to early death. Cancers of lung, blood and brain have different rates of progression than cancers of tongue, mouth and jaws. Nonetheless, all forms of cancers will result in permanent disfigurement and disability. Interestingly, the only other commonality between most cancers is the relationship to tobacco which remains as the root cause. Undoubtedly, tobacco is the strongest cancer providing consumer product. There can be no greater truth than what was said by the WHO Director General, Dr Gro Brundtland:  “A cigarette is the only consumer product which when used as directed kills its consumer.”
The same sentiment was truthfully  echoed by Anne Edwards by Philip Morris, the major multi-national tobacco company:  "What I think is clear is if someone came to us with a cigarette today and said, hey, here is a new product, I'm going to bring it to market.  Would it be allowed in the market anywhere? No, it would not. It is a very harmful product" (on Sex, Lies and Cigarettes)

Tobacco is also responsible for a large number of non-cancer diseases. It can be easily listed as the number one cause for a majority of heart attacks, strokes, chronic respiratory diseases and general ill health.  In women of child bearing age, tobacco is responsible for infertility, prematurity and low birth weight of new born babies, and abortions.

Smoking is not just injurious for a smoker. It damages the health of non-smokers who live in the company of smokers. This is a type of second hand or passive smoking which is directly related to cancers and other diseases. Such relationship which was first shown amongst non-smoker wives of smokers from Japan, has been also reported from a large number of other countries.

The only valid argument which the Committee has put forwards is related to the loss of jobs for b­­idi workers and tobacco farmers. A large number of studies are now available which show that the overall economic loss from tobacco related hazards is far more than the revenue loss from tobacco. A number of remedies including alternate crops have been suggested in several reports to compensate for the losses of farmers. Undoubtedly, the health is the most crucial issue and tobacco-control forms the core for National Disease Control Programmes of Government of India. One cannot lose sight of the fact that the Government of India is signatory to the International Frame Work Convention on Tobacco Control. The country is committed to undertake several mandatory steps to reduce consumption and production of tobacco.

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Dr Surinder K. Jindal, MD, FCCP, FAMS, FNCCP

(Ex-Professor & Head, Department of Pulmonary Medicine

Postgrad Instt of Med Edu & Res, Chandigarh, India)

Medical Director, Jindal Clinics, SCO 21, Dakshin Marg, Sector 20 D,

Near Guru Ravi Das Bhawan, Chandigarh, India 160020.

Email: dr.skjindal@gmail.com

Website: jindalchest.com

Ph.  Clincis: +91 172 4911000,  Res.  +91 172 2712030/ 31

Extrapulmonary tuberculosis

From Hunchbacks to King’s  Evil

 Tuberculosis of Non pulmonary organs

Whenever I suggest the diagnosis of tuberculosis in an individual with a swelling in the neck, I face the immediate retort- “I do not have cough or any other lung symptom for that matter. How can I suffer from tuberculosis?” Factually, tuberculosis can not only involve the non-pulmonary organs, it does so frequently, and rather with an increasing tendency in the modern era. Historically however, tuberculosis of non- pulmonary organs, such as the bones was recognized long before the lung involvement came to be known. The portraits of hunchbacks pictured by the Egyptian artists on the wall of the tombs of over 5000 years earlier, are considered to suggest the tubercular vertebral destruction, now known as caries of the spine. Remnants of skeletal tuberculosis have been found  in the Neolithic Mediterranean and Ancient Egyptian mummies.  It is also said that the queen Nefertiti and her husband king Akhenaten of ancient Egypt died of tuberculosis. The presence of skeletal tuberculosis was substantiated further by the examination a well preserved Egyptian “mummy” of 3400 B.C. in whom the vertebral destruction and an associated abscess could be clearly ascertained. The mention of lung tuberculosis can be found only in the later descriptions, in the ancient Chinese, Babylonian and Indo Aryan literature of 2600-1500 BC era, about 1-2 millennia later than the skeletal tuberculosis.

Tuberculosis affects not only the humans but also the members of most other living species. Man first acquired tuberculosis from the cattle. A recent article in the premium scientific journal Nature reports an interesting observation that the transmission of tuberculosis to humans occurred from the seals, and that the history of origin of tuberculosis may be relatively recent than was previously believed. The finding has been however contested by other scientists who recognize the disease to be more ancient.

History aside, tuberculosis is unique for its ubiquitous nature and a wide variety of clinical manifestations. Tuberculosis is known as primarily a disease of the respiratory system, particularly the lungs. It is one of the few diseases which can involve almost any part of the body. Cancer is also known to affect any organ, but cancer is not a single disease. Cancers of different sites have different causes, treatments and natural course. On the other hand, the cause of tuberculosis of any organ is the same i.e. the micro-organism, Tubercle bacillus – also called the Mycobacterium tuberculosis. The treatment and natural course of tuberculosis of different organs are broadly similar with minor variations.

Tuberculosis continuous to pose a global health challenge with over 8 million new cases and about 1.3 million deaths every year. India alone accounts for about one fourth of the global burden. Over 15 percent of patients of tuberculosis suffer from disease of the organs other than the lungs i.e. the extra pulmonary tuberculosis. This type of tuberculosis is important for several reasons: It is a poorly recognized clinical entity; is difficult to diagnose and treat, and carries a significant morbidity and mortality.

After the lungs, the lymph nodes constitute the most common sites for tuberculosis. Lymph node

tuberculosis, known as the King’s Evil, scrofula or struma was widely recognized during the Middle

Ages in Europe where the royality touch was believed to cure the disease. King Henry IV of France is

said to have touched as many as 1,500 individuals at a time while Charles II of England is said to have cured more than 90,000 victims between 1660 and 1682. Lymph nodes comprise of small nodular glands of lymphatic tissue present in the superficial  regions in the neck, axillae, elbows and groins; and deeper region in thorax, abdomen and pelvis. While the superficial nodes when involved with tuberculosis, are either visible or palpable; the deeper lymph nodes are not easily detected. The enlarged glands may press upon or erode the surrounding structures, resulting in the onset of different clinical symptoms and signs. The superficial gland enlargement may appear innocuous, but highly demoralizing, particularly in case of younger individuals. I am aware of a case when an otherwise well planned marriage broke down because of the presence of an enlarged lymph node in the neck of the girl.

Pleural tuberculosis is the second most common extra pulmonary site of tuberculosis. It results in accumulation of fluid in the pleural cavity surrounding the lungs, causing lung compression and breathlessness. Fluid can similarly accumulate in the pericardial cavity around the heart and the peritoneal cavity in the abdomen. The diagnosis is these cases is made by the examination of the fluid obtained by aspiration.

Tuberculosis of brain and its covering membranes, the meninges is a serious form of tuberculosis especially common in children. Delayed diagnosis can result in marked disability complications such as mental retardation, paralyses, blindness, deafness, or sometimes death. Tuberculosis of spine may similarly prove to be serious and disabling. The cold abscess formation and vertebral destruction may result in spinal cord compression and cause paraplegia (paralysis of both lower limbs), and sometimes quadriplegia (paralysis below the neck), depending upon the site of the lesion.

Almost any bone other than the spinal vertebrae can also be involved. Tuberculosis of the intestinal tract may result in intestinal obstruction while genitourinary tuberculosis can cause infertility, blood in the urine or urinary obstruction. Other sites which can sometimes be affected include the heart, the skin, the mucus membranes, the throat and the eyes. Importantly, the organ involvement also determines the disease-severity and type of residual damage which tuberculosis can leave even after healing.

Tuberculosis of the non-pulmonary organs is difficult to diagnose for several reasons, most importantly because of the lack of  awareness  and disease-suspicion. The disease manifestations are highly variable to conform to a specific pattern. It is generally late when the disease is first suspected. The Revised National Tuberculosis Control Programme of Government of India advocates sputum examination for diagnosis of pulmonary tuberculosis if the patient complains of cough that lasts for over two week duration. There are no definite guidelines to suspect and diagnose extra pulmonary tuberculosis. Therefore, the disease continues to advance without being checked in time.

It is also difficult to establish the diagnosis because of the lack of ease to obtain the appropriate specimens for testing. Unlike pulmonary tuberculosis where sputum examination and chest x-ray are the easy to do tests, most of the extra pulmonary organs require invasive-investigations and biopsies for diagnosis. Such tests are difficult for patients to undergo and carry some inherent risks, even if small. Moreover, the tests cannot be frequently repeated. There are other problems related to medical decisions, for example when to start the treatment, how to monitor the progress and decide the end-point.  It is also very difficult to decide about the disease-persistence, recurrence or development of drug resistance (etc). A large number of decisions are essentially empiric  based on soft criteria rather than hard scientific evidence.

The broader principles of treatment of tuberculosis of non-pulmonary organs remain the same as for the treatment of the lungs. There are a few controversies among different subject experts, for example about the duration of treatment. As per the Revised National Tuberculosis Control Programme guidelines, the prolongation of therapy, but for spinal, neurological and cardiac tuberculosis, does not provide any additional benefit. The ortho-pedicians, neurologist and cardiologists generally tend to give treatment for  longer periods.

There is a general increase in the number of patients with extra pulmonary tuberculosis. Presence of other comorbid conditions such as diabetes, and other immuno-suppressive conditions, particularly the Human Immunodeficiency Virus (HIV) infection are partly responsible for this increase. Unfortunately the consequences of non-pulmonary forms of tuberculosis are more fearsome. Thus, there is a greater need to be cautious and careful.

Origin of tuberculosis

In their attempt to look into the history of tuberculosis, an international group of archaeologists and geneticists searched for tuberculosis DNA in 68 sets of remains of bone samples in 2012.  The scientists could recover the genetic material in three 1000 year- old mummies from Chiribaya culture of southern Peru. The most closely related DNA belonged to the tuberculosis strains found only in seals. Possibly the hunters picked up tuberculosis from seals. The fossil evidence however suggests that tuberculosis is far older.

Burden of extra-pulmonary tuberculosis

Nearly one-third of the world population (app. 2 billion) is infected with tuberculous bacilli while over 8 million develop tuberculosis every year. The 2012 global figures released by the World Health Organization suggested an estimated 8.6 million new cases and 1.3 million TB deaths. India alone accounted for 26% of new cases while China contributed about 12 percent. On the other hand, the Western countries account for an incidence rate of less than 10 cases per 100000 population. About 1.2 million people suffered from tuberculosis of organs other than the lungs. Extra-pulmonary TB remains difficult to diagnose and treat in most situations.

From Louvre museum, Paris

The glorious Queen Nefertiti and King Akhenaten of ancient Egypt (ca.1370 BC- ca.1330 BC)

are believed to have died of tuberculosis.

_____________________________________________

Dr Surinder K. Jindal, MD, FCCP, FAMS, FNCCP

(Ex-Professor & Head, Department of Pulmonary Medicine

Postgrad Instt of Med Edu & Res, Chandigarh, India)

Medical Director, Jindal Clinics, SCO 21, Dakshin Marg, Sector 20 D,

Near Guru Ravi Das Bhawan, Chandigarh, India 160020.

Email: dr.skjindal@gmail.com

Website: jindalchest.com

Ph.  Clincis: +91 172 4911000,  Res.  +91 172 2712030/ 31