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Positive Health

Health in broad sense does not merely means absence of disease or provision of diagnostic, curative, and preventive services. It also include as defined by WHO in its definition of health, as a state of physical, mental and social well being. The harmonious balance of this state of humans when integrated in his environment, constitute Positive Health.

The Positive Health implies the notion of “perfect functioning” of the body and mind. The Positive Health conceptualizes health biologically, as a state in which every cell and every organ of the body function at optimum level and in perfect harmony with the rest of the body. It conceptualizes health psychologically, as a state in which individual feel a sense of perfect well being and socially, as a state in which the individual’s capabilities for participation in the social system are optimal. These were the ideas of positive health few years ago, but at present in practical point of view, these ideas seem to be little ridiculous.

“The concept of perfect positive health can not become a reality because, men will never be so perfectly adapted to his environment that his life will not involve struggle, failures and sufferings” Dubos has said. Because everything in our life has to change, therefore perfect positive health will always remain a mirage. In this concept health has been described as a potentiality. The ability of an individual or social group, to modify itself continually, in the face of changing condition is what defines positive health. Doctor and community health worker face with the same situation, as faced by a farmer for insects. The job is never is done.

Recently, a broader concept has emerged, that the quality of life has been an essential part of health. The quality of life depends on not only medical action, but also economic, cultural, social factors operating in the community.

Concepts of Health: a Broad Perspective

Health is one of those terms which most people find it difficult to define although they are confident of the meaning of health. World Health Organization (WHO) defines health as follows “health is a state of complete physical, mental and social well being and not merely an absence of disease or infirmity”. In recent years the definition has been amplified to include the ability to lead “socially and economically productive life”. Many people criticize this definition as too broad. Some people say health can not be defined as “state”, and it is a process continuous adjustment to the changing demands of living. Health is a dynamic concept. Health helps people to work well, live well and enjoy themselves. That’s why many people consider the WHO definition of health as too idealistic, rather than realistic. The definition refers to situations that may exist in some but not all the people at a time. It is irrelevant to everyday demand as nobody can qualify as healthy that is perfect physiological, biological, and social functioning. In sort if we accept the WHO definition of health, we all are sick.

Dimensions of health:

1) Physical dimension: it implies the perfect functioning of the body. It is a biological state in which every cell and every organ is functioning at optimum capacity and is in perfect harmony with the rest of the body. The signs of physical health are a clean skin, bright eyes, lustrous hair, firm flesh, not too fat, a sweet breath, good appetite, sound sleep, regular activity of the bowels and bladder and smooth easy coordination of body movements.

2) Mental dimension: mental health is not mere absence of mental disease. It is the ability to respond to varieties of experiences of life with flexibility and a sense of purpose. If a person can not respond with confidence to different experiences of life, he is not healthy mentally.

3) Social dimension: social well being is harmony and integration within the individual, between each individual and other member of society and in the world where they live. Social dimension is the quantity and quality of an individual’s interpersonal relationships and the extent of involvement with the community.

4) Spiritual dimension: time has come to give serious consideration to the concept of spiritual dimension of health. It is the ‘something’ intangible that transcend physiology and psychology.

5) Emotional dimension: historically mental and emotional health was seen as a single unit. But as new research is coming out the difference is emerging. Mental health is “knowing” or “cognition”, but emotional health is more of “feeling”.

6) Vocational dimension: it is a new dimension and part of human life. When work is fully adapted to the human goal, capacity and limitation, it plays a role in promoting physical and mental health. The importance of this dimension is exposed when a person lose his job or faced with mandatory retirement.

7) Other dimensions: a few other dimensions are also suggested like philosophical dimension, cultural dimension, socioeconomic dimension, educational dimension, environmental dimension, nutritional dimension, curative dimension and preventive dimension.

Marine Poisoning & its management

Scombriod poisoning

Scombriod fish (mackerel like) include bluefin and yellowfin tuna, albacore, needle fish, skipjack, bonito etc. non scombroid fishes can also contain scombrotoxin. Poisoning with scombrotoxin is called pseudoallergic fish poisoning.

Under inadequate refrigeration/preservation these fishes undergo baterial decomposition and formation of amino acid L- histidine to histamine, histamine phosphate, and hydrochloride. Histamine level of 20 to 50 mgs/100 gm of fish has been noted. But it may be as high as 400 mg/100 gm. The toxin is heat stable and not destroyed by cooking or heating. Affected fish is of typical taste, but it may be without any specific taste or odor. Distribution of poison may not be same, this explain why some people do not get sick after eating same fish.

Symptoms develop within 15 minutes to one hour. Itching, urticaria, flushing which is sharply demarketed, nausea, vomiting, diarrhea, abdominal cramps, epigastric pain, headache, difficulty in swallowing, thirst, burning of mouth, dizziness, high pulse rate, feeling of warmth without increase in core temperature. These symptoms may resolve without any treatment within a day.

Treatment include antihitaminics and symptomatic treatment.

Paralytic Shellfish Poisoning

Paralytic Shellfish poisoning is induced by ingestion of aquacultured filterfeeding organisms like oysters, clams, starfish, mussels, scallops, and sand crabs etc. The toxin they have is accumulated by feeding the planktons where they live. The toxin is water soluble and heat stable. It can also kill large numbers of marine life. Commonest toxin is saxitoxin.

Symptoms appear within few minutes of ingestion of the toxin. It includes loss of sensation of tongue, lips, gums, which may progress rapidly to neck and extremities. Other symptoms include lightheadedness, incoordination, disequilibrium, incoherence, weakness, thirst, salivation, difficulty in swallowing, diarrhea, vomiting, abdominal pain, headache, loss of vision etc.

Treatment is supportive and based on symptoms.

Ciguatera poisoning

Ciguatera poisoning is the commonest non bacterial food poisoning associated with fish in USA, most of the cases occurs in Florida and Hawaii. Poisoning involves tropical and subtropical coral reef fish. Poisoning involve five different types of toxins. These toxins are heat, cold, drying, and gastric acid resistant. These five toxins are colorless, tasteless, and odorless.

Symptoms occur within 15 to 30 minutes of ingestion. They include abdominal pain, diarrhea, vomiting, chills, itching, numbness of throat and tongue, sensation of ‘carbonation’ during swallowing, tremor, fatigue, and headache.

Treatment is symptomatic and supportive. Activated charcoal (100 gm) in sorbitol is useful if given within three hours of ingestion of the toxin. Sedatives can be given if patient is apprehensive. Adequate hydration should be given if there is dehydration.

Snake Bite & its Management

There are thousands of different species of snakes in the world. But very few of them are poisonous. More than 50,000 people die each year due to poisonous snake bite. This may be only the tip, because many go without reporting. Venomous snakes are divided into the following categories Viperidae (old world vipers, asian pit vipers etc), Elapidae (cobras, coral snakes and Australian venomous snakes), Hydrophiidae (all sea snakes), Atractaspididae (burrowing asps), and Colubridae.

It is very difficult to differentiate venomous from non venomous snakes. Fang marks are of no diagnostic value. Symptoms of snake bite include fear of impending death, nervousness, local swelling, redness of the site, sharp pain. More than 20% (75% of sea snakes) of the bite are ‘dry’ type which means either no venom or insufficient venom to cause serous problem or death.

First Aid Measures: If the bite of the snake is in limb it should be immobilized and firm pressure bandaging of the bite area and few inches above the bite site should be tied. These measures significantly delay the spread of the venom. Patients are generally apprehensive and nervous and they should be reassured and sedated if necessary.

Treatment of snake bite:

1) The site of the bite should be cleansed properly and left strictly alone. Nothing should be done with the bite site, otherwise chances of infection increases. Tetanus prophylaxis should be done with tetanus toxoid. If there is necrosis of skin, it should be sloughed off and skin grafting if required.

2) If required sedatives can be administered. General measures like intravenous fluids should be given.

3) Anti venoms should be given only if there is clear evidence of systemic poisoning. But some authorities prefer to give anti venom within four hours if diagnosis of snake bite is confirmed, to avoid necrosis. Anti venom is available for some common snakes only depending on the country, within country also different regions have different types of snakes so also anti venom. If snake is not common in an area anti venom for that particular snake may not be available. If it is available than it should be made sure that it is clear and has no opacities. Depending on the severity 20 to 100 ml is diluted in two units of normal saline and given by slow infusion. Adrenalin (1:1,000 solutions) should be kept ready in case anaphylactic shock (dangerous allergic reaction) develops. Giving anti venom at the earliest is very important because once the venom is lodged it is very difficult to dislodge the venom from the site.

Scorpion Stings

Scorpions are arachnids that feed on arthropods, lizards, which they grab with crablike claws and inject paralyzing venom from stinger which is present at the tip of the tail. There are about one thousand different species of scorpions, out of which only the bark scorpion in USA produces venom which can be lethal to humans. Scorpion sting cause about 5,000 deaths every year worldwide. They feed at night and remain hidden at day time. They like cool places and can enter houses and hide in shoes, cloths, bedding or may enter sink in search of water. Scorpions stings humans only when disturbed.

Scorpion sting can cause sharp local pain, which is followed by swelling of the area, burning sensation, itching etc. Allergic reaction may develop. If condition is severe there will be restlessness, blurring of vision, salivation, lacrimation, running nose, speech difficulty. Muscle cramp, drop in blood pressure, seizure, nausea, vomiting can occur. Symptoms become severe in 5 hours and subside in a day or two.

Offending scorpion should be tried to identify. Treatment of scorpion sting consists of local application of ice pack, cleaning of the bite site, tetanus prophylaxis with toxoid. Painkillers like brufen, diclofenac and antihistaminics like cetirizine, fexofenadine can be given for symptomatic relief. Patient should be advised to be calm and reassurance is given. Specific antivenin if available should be administered in serious cases. But antivenin should be reserved for selected cases only because it can cause potentially dangerous side effects. A C. sculpturatus antivenin is available but not yet approved by FDA. It is available in Arizona State University for use in Arizona only, mainly for research purpose.

Spider Bite: Recluse Spider Bite

There are more than 30,000 recognized spider species in the world. But only about 100 defend themselves aggressively and have fangs long enough to penetrate human skin and can cause harm to humans. Bites of the most spiders are painful but do not cause any harm. The venom that spiders use to hunt their prey can cause necrosis of skin and systemic toxicity. Bites of spiders like brown recluse spiders, widow spiders and very few other species can be life threatening. Specific treatment for spider bite like widow and brown recluse spiders is available, so offending spider should be tried to identify. In many cases it is seen that injury is by something else but spiders are attributed as the offender.

The scientific name of the recluse spider is Loxosceles recluse. Recluse spiders are found southern and Midwestern USA. They are about 0.7 to 1.5 cm in body length and 2 to 4 cm in leg span. Recluse spiders are brown in color and they have violin shaped spot on their surface. Recluse spiders do not spin web. They are not aggressive toward humans and bite only when they are provoked or threatened, or pressed against skin. They invade homes particularly during fall and hide in undisturbed dark places like closets, in furniture, store rooms, garage, and folds of cloths. That’s why bites are common while dressing and the common sites are arms, neck and abdomen. In wild they hide under rocks and logs and in animal burrows and caves. They emerge at night to hunt insects and other spiders.

The venom of recluse spider is clear and viscous and it contain an esterase, alkaline phosphatase, protease and other enzymes which produces hemolysis (breakdown of blood cells) and tissue necrosis (death of tissue). Sphingomyelinase B is the most potent enzyme which causes vascular thrombosis and tissue necrosis. At the beginning the bite is painless, but after few hours the site of the bite becomes painful and itching. The bite site becomes hard and it is surrounded by a pale zone (due to lack of blood and oxygen) and a zone of redness. Maximum cases the lesion resolve spontaneously without any treatment in a few days. But if it is not resolved within 2 to 3 days, the red surrounding spreads, the central pale becomes hemorrhagic and dies. This part sloughs off and a big ulcer forms which, may be sometimes as big as one foot in diameter. It eventually becomes a big depressed scar. Healing of the scar may take up to 3 to 6 months. If subcutaneous fat is involved it may take 3 years to heal properly. Complications of recluse spider bite include secondary infection and injury to nerves. Nausea, vomiting, weakness, fever, chills, headache, rash, painful muscles, arthralgia may develop after the bite. Very rarely renal failure, hemolytic anemia may cause death.

Treatment of Recluse Spider bite:

Initial treatment includes local cleansing of bite site, icepack, dressing and elevation and immobilization of limb if the bite site is limb. Treatment with painkillers, antihistaminics, antibiotics and tetanus prophylaxis is given. If lesion is becoming necrotic dapsone, a leukocyte inhibitor is given within 2 to 3 days, which prevent progression of the lesion. Dapsone (used in treatment of leprosy) is given at the dose of 50 to 100 mgs twice a day orally. Glucose 6 phosphate dehydogenese deficiency should be ruled out before giving dapsone. Loxosceles specific antivenom is not approved in USA. Cleaning of wound and removal of dead tissues should be done. Immediate surgical removal of wound is very useful in serious cases. Finally skin grafting is required in most cases. Patient should be observed for the development of renal failure, hemolysis and other systemic complications.

Preventive measures like wearing full sleeve heavy shirts, full trousers (not half pant or bermuda’s), and hand gloves should be kept in mind while working outdoor and in dark areas indoor in the localities where widow spiders are commonly found.

Spider Bite: Widow Spider Bite

There are more than 30,000 recognized spider species in the world. But only about 100 defend themselves aggressively and have fangs long enough to penetrate human skin and can cause harm to humans. Bites of the most spiders are painful but do not cause any harm. The venom that spiders use to hunt their prey can cause necrosis of skin and systemic toxicity. Bites of spiders like brown recluse spiders, widow spiders and very few other species can be life threatening. Specific treatment for spider bite like widow and brown recluse spiders is available, so offending spider should be tried to identify. In many cases it is seen that injury is by something else but spiders are attributed as the offender.

Widow Spider Bite:

The scientific name of widow spider is Latrodectus mactans. The bite of the female widow spider is dangerous and notorious due to its potent neurotoxin. The black widow spider is found in all of USA except Alaska. It is more common in Southeastern parts of USA. It is about 5 cm in length with a body of one cm. It is shiny black in color and has a red hourglass marking in the abdomen. The red widow and the brown widow are other dangerous types of widow spiders.

Bites are most common during summer and early autumn when their web is disturbed or when they are trapped or provoked. They spin their webs in logs, plants, rock piles, under stones or in dark areas like garages or outhouses. Buttocks are the site of bite if the person sits on a spider. It goes unnoticed at first or may be thought as a sharp pinprick. If examined properly two small red marks will be seen and there will be swelling around the marks. ? latrotoxin which is the most active component of the venom is yellowish and oily in color and may not cause any problem or it may be cause serious toxicity by binding irreversibly to nerves and cause release and depletion of acetylcholine, norepinephrine and other neurotransmitters. In less than half hour painful cramps spread from bite site to large muscles of trunk and limbs. Symptoms like salivation, vomiting, high blood pressure, diaphoresis, breathing difficulties, high pulse rate, weakness, headache, anxiety, urinary retention, hyperreflexia, fasciculation, uterine contraction and premature labor can occur. Peritonitis may develop, which is suggested by rigidity of abdominal muscles and excruciating pain. But there may not be any pain on pressure to abdomen. In very weak and frail person, elderly and young person it may cause renal failure, respiratory arrest, cardiac arrest, brain hemorrhage and death. Excruciating pain may last for several weeks or it may subside in a day.

Treatment of Widow Spider Bite:

At first cleaning of the bite site with plain water, ice packing, and tetanus prophylaxis should be given. If there is high blood pressure it requires specific antihypertensive therapy because it can not be controlled symptomatically. Specific equine antivenin is available but due to its high risk of anaphylaxis and serum sickness it should be reserved for serious cases only. The equine antivenin is administered intravenously relieve pain rapidly. One or two vials are usually sufficient.

Preventive measures like wearing full sleeve heavy shirts, full trousers (not half pant or bermuda’s), and hand gloves should be kept in mind while working outdoor and in dark areas indoor in the localities where widow spiders are commonly found.