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- The
Global Medical Forum, Pontresina,
Switzerland
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- TECHNOLOGY
AND THE DEVELOPING WORLD
- Lecture by
Beat Richner, M.D., Cambodia
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- The Global Medical
Forum, Pontresina, Switzerland
- Day Three:
Wednesday, 19 September 2001
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- Mr. Chairman,
Ladies and Gentlemen,
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- In my statement on
Monday, I alluded to the fact that the protocols
designed by the International Community about handling
of health care in poor countries for poor people do
not foresee basic technologies for diagnosing and
understanding disease, technologies that are
undisputed in the first world. Moreover, fundamental
technologies are discredited as luxury and as "Rolls
Royce Medicine", too sophisticated for a poor country
such as Cambodia for instance.
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- I would like to
demonstrate the importance of such technology not only
for the individual but also vis-à-vis of public
health using as an example a disease condition
recently discovered in one of our Kantha Bopha
hospitals. We were just celebrating the
"break-through" in the understanding of a frequently
occurring severe disease in newborns which turns out
to be congenital tuberculosis.
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- Congential
tuberculosis confirmed
- We were able to
confirm the presence of congenital tuberculosis in the
neonatal unit at Kantha Bopha I. While we had
diagnosed tuberculosis before in older children
presenting with dermatologic lesions including
subcutaneous abscesses, we now detected TBC-bacillus
in the gastric secretion of newborns with similar skin
lesions. This means that these infants must have been
infected either during pregnancy or
perinatally.
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- We had suspected
for a long time that numerous babies might have been
infected already by the time of their birth, a fact
that has been and still is unknown , since we keep
discovering most severe manifestations of tuberculosis
in more and more children at an ever younger age: for
instance miliary tuberculosis at the age of six weeks
or vanishing vertebral bodies caused by systemic
tuberculosis at the age of four months with subsequent
irreversible paraplegia. During the current year 2001,
we experienced sofar 54 children with proven
tuberculous osteomyelitis of the spine. In such severe
cases one must postulate that the infection has
occurred weeks or months before which means at least
during delivery or, possibly, before
birth.
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- With regard to the
actual general increase in number of young children
and infants affected by tuberculosis, we assume with
certitude that there is a direct link to the expanding
AIDS epidemic. Under the acquired immune deficiency,
young adult carriers of the TBC bacillus are prone to
get active tuberculosis and, thus, to spread the
disease.
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- Congenital
tuberculosis as a factor of the "Kantha Bopha
Syndrome"
- Six years ago, we
discovered a severe disease condition which we named
the "Kantha Bopha Syndrome". Its preceeding history
and course are characteristic: There is an initial
eposide of fever over three days. In 50% of cases,
mothers describe the presence of diarrhea; in 20%,
mild vomiting is observed. On day three to four, the
voice is changing into a hoarse and low vocal tone.
Also on day four, the eye movements are becoming
incoordinated, frequently associated with generalized
seizures. On day five to six, there is additional
tachypnea until day ten to eleven when the child dies
unless he or she survivs the seizures.
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- The fact that TBC
bacillus is now found in the gastric secretion of
newborns indicating the presence of tuberculosis at
this age lead us to the idea to look for the same
finding in the slightly older infants who belong to
the age group of children affected by the "Kantha
Bopha Syndrome" (probably thousands), i.e. infants
between two and ten months of age. Within the last
weeks we were able to isolate TBC bacillus from
gastric secretions of these children. This seems to
confirm our hypothesis that tuberculosis may be at the
base of the "Kantha Bopha Syndrome", and possibly its
main factor.
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- Misinterpretation
by the WHO
- Since 50% of these
children suffer from diarrhea, they are, together with
all children in the third world who suffer from
diarrhea, registered by the WHO as "diarrhea disease",
i.e. gastroenteritis. It is said for instance that in
Bangladesh the diarrhea disease is "under control".
The mortality however is unchanged...! Also, third
world children with tachypnea are registered by the
WHO as suffering from infection of the respiratory
tract. Therefore, the majority of children's mortality
in the third world are believed by the WHO to be due
to diarrhea and respiratory tract
infection.
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- However, both
tachypnea as well as diarrhea are but symptoms. Thanks
to adequate diagnostic means it was possible to
investigate and document over the past six years what
in fact happens to thousands of these children. In
addition, thanks to targeted and efficient therapy,
the mortality of these could be reduced from 63 to 7
%. Accordingly, it was also possible to reduce the
number of children with permanent brain damage as a
consequence of the "Kantha Bopha Syndrome". In
children affected by the syndrome who are admitted
only on day eight or later after the onset, the
prognosis is compromised.
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- Evident findings
thanks to modern diagnostic means
- Using
ultrasonography (US) and computed tomography (CT) in
children affected by the "Kantha Bopha Syndrome", one
can demonstrate characteristic lesions in the basal
ganglia. As of day three of the disease, changes in
the area of the striate vessels can be detected, most
likely due to local vasculitis and leading to local
infarction from vascular compromise. These lesions
also explain neurologic symptoms (e.g. hoarse voice,
seizures and somnolence).
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- Due to the elevated
pulmonary resistence around day five to six of the
disease echocardiography allows to estimate the
increased pulmonary pressure leading to rigth cardiac
ventricular hypertrophy over the following days. Its
massive degree is measured by US. Radiologically, the
lungs are clear, but there is moderate to severe
cardiac enlargement. Thus, tachypnea is not due to
lung or bronchial disease, but is compensatory for the
child's acidosis from cardiac insufficiency. Within
days, cardiac failure will be fatal, typically around
day eleven of the disease.
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- We hypothesize that
pulmonary hypertension leading to cardiac
insufficiency may be caused by pulmonary vasculitis.
But unlike the cerebral manifestation of vascular
inflammation that can be shown by US, we do not have
the technical means to demonstrate such a process in
the lungs. There may be other organs systems involved
by some form of vasculitis.
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- Furthermore, in all
of these children the number of thrombocytes is
elevated. Thrombocytosis is characteristic and
significant in tuberculosis of older children. We made
this observation already in 1995 and believed to have
made a discovery. However, this has been observed in
the twenties of the 20th century but seems to have
been forgotten since. Now, we detect tuberculosis
again in the gastric secretion of these children with
"Kantha Bopha Syndrome" and thrombocytosis. In
addition, we could demonstrate the presence of
japanese encephalitis virus in numerous children with
"Kantha Bopha Syndrome".
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- What does really
happen? All these children are infected with TBC and,
thus, deprived of adequate defense mechanisms against
infections. A viral infection, for instance by the
japanese encephalitis virus, leads to fever and
diarrhea lasting commonly for three days. The viral
infection seems to initiate the severe "Kanthe Bopha
Syndrome", i.e. the inflammatory vascular changes with
their consequences as described above.
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- Sevenhundred
children with "Kantha Bopha Syndrome" died at Kantha
Bopha I hospital in 1996
- On the day of
inauguration of the Kantha Bopha II hospital, October
12, 1996 under the auspices of His Excellency King
Norodom Sihanouk and the President of the Swiss
Confederation, the late Jean Delamuraz, 16 children
died at Kantha Bopha I hospital from the "Kantha Bopha
Syndrome". During the entire year 1996, 700 children
died at the same hospital from the sequelae of this
syndrome. According to the protocols of WHO all of
these children would have been noted to have died as a
consequence of diarrhea and respiratory tract
infection.
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- Adequate diagnosis
and therapy are possible
- With the opening of
the Kantha Bopha II hospital US including color
Doppler and a simple CT unit produced by General
Electric were installed. During the inauguration
ceremony, the Swiss President Jean Delamuraz told to
King Norodom Sihanouk the historically significant
sentence: "If someone calls this equipment luxurious
or too sophisticated for a poor country like Cambodia,
he is a neocolonialist". Yet, all experts, whether
international or national, criticized and despised the
acquisition of the CT unit.
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- Thanks to the
equipment mentioned above we were able to recognize
and understand the pathophysiologic processes
occurring in the heart and brain of children affected
by the "Kantha Bopha Syndrome". It has nothing to do
with "diarrhea disease" and airway infection. The new
laboratory equipment for serology allows us to prove
the presence of Japanese encephalitis virus infection
causing brainstem disease. The chemical laboratory
enables early recognition of renal insufficiency,
possibly due to renal vasculitis. Now, today, we are
able to prove directly the presence of TBC bacillus in
the gastric secretion and elsewhere.
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- Since the end of
1996 we are able to treat these children successfully
using cortisone with the aim at reducing the
inflammatory process of small vessels and to prevent
cerebral edema; simultaneously, we intend to prevent
bacterial superinfection of the young patients with
their generally deteriorated health condition by
adding the antibiotic Ceftriaxon. In addition, under
the hypothetical assumption of an underlying
tuberculosis, we added tuberculostatic drugs which, as
it turns out by directly proving the presence of TBC
bacillus, was a correct means. Further therapeutic
measures are by fluid and electrolytes in order to
reinstall diuresis and treat renal as well as cardiac
insufficiency and the use of vitamin B which has only
some transient effect. We conjecture that TBC bacilli
consume thiamin.
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- We apply the above
"cocktail" during ten days, while the tuberculostatic
drugs are continued for six months. After the initial
ten day therapy, the children are discharged and seen
at regular intervals in the special outpatient ward
for tuberculosis. After six weeks, the cardiac
findings become normal; and cerebral lesions regress
to normal in most children who did not develop
permanent brain damage, i.e. who underwent timely
treatment. In the minority of patients who discontinue
tuberculostatic treatment, the recurrence of "Kantha
Bopha Syndrome" is a frequent complication at any
viral reinfection.
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- In order to fight
successfully for the prevention of the "Kantha Bopha
Syndrome" which affects, as we know, thousands of
young children, we have to eliminate the neonatal,
i.e. "congenital" tuberculosis. This means that
pregnant mothers have to undergo treatment. The BCG
vaccination obviously doesn't help at all. In
addition, vaccination against the Japanese
encephalitis virus seems indispensable, since it has
been shown that this virus is initiating the syndrome
in numerous cases.
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- Prevention of
congenital tuberculosis and "Kantha Bopha Syndrome"
with the help of a maternity clinic
- A new maternity
clinic will open on October 1st 2001. This will give
us the opportunity to examine systematically the
uterus and placenta before birth by US as well as
every placenta histopathologically for the presence of
tuberculosis; we will as well look for TBC bacillus in
the amniotic fluid. We hope to be able to provide more
precise information as to the time of the assumed
vertical transmission of tuberculosis. The pregnant
mother may just be a carrier of TBC bacillus; she may
have to be treated tuberculostatically in order to
prevent the "Kantha Bopha Syndrome" in her newborn. A
further rationale of the maternity clinic is to
attempt prevention of congenital HIV
infection.
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- It may be the first
time in history that the pediatrician installs a
maternity clinic in order to protect the child from
disease when there is still time for protection, i.e.
before birth. This project is reaching out far;
therefore it is highly supported by the Swiss office
for development and cooperation in Bern (DEZA:
Direktion für Entwicklung und Zusammenarbeit),
especially by its director the Ambassador W.
Fust.
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- The International
Community and their experts and functionaries are
paralyzing until this day any kind of technological
innovation necessary for the care of the individual as
well as the public health. I could sing you a song
about this attitude; that is why I created the song
and take the liberty to sing it for you
now.
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- English translation
by Ulrich V. Willi, M.D.
- University
Children's Hospital, Zürich,
Switzerland
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