PROMOTION OF BREAST FEEDING
AUGUST 7, 2023
We have been celebrating World Breastfeeding Week from August 1 to August 7 every year since 1992. It is a sad fact that only 44% of infants in the first six months of life were exclusively breastfed over the period of 2015–2020. One cannot overstate the importance of breastfeeding for both mother and child. The reasons for denying breastfeeding are many: family, social, cultural, medical, and economic, to name a few. At a meta-level, it is disturbing that something so basic as breastfeeding, a necessary part of any species evolution, needs aggressive promotion and advertisement uniformly across all countries in the world.
As basic biology texts make it clear, the three basic qualities of living organisms are protection, growth, and propagation of species. The last is to prevent the extinction of species. Evolution works as a dynamic interplay between nature and the species to nurture these three basic qualities. Breastfeeding is extremely basic for our survival (and arguably our success) as a mammalian species. Among the other factors contributing to removing the infant from breastfeeding are the present narratives of individualism and the utilitarian approach to gender equality. Society is dangerously losing its understanding of the exclusive value that birthing, motherhood, and lactation bring to women. One author significantly says that attacks on the most obvious institutions maintaining female accessibility to males—heterosexuality, marriage, and motherhood—form the core triad of feminist ideology. There is something problematic when a biological function becomes a matter of rights or an impossibility to execute because of the many factors around us. If we need to promote breastfeeding, the fundamental brick of species survival, are we really progressing and evolving as human beings?
TRAINING OF UNQUALIFIED PEOPLE AS ‘DOCTORS’ A DANGEROUS MOVE
JULY 13, 2023
In India, there is increasing specialised healthcare for those who can afford it. The gap between medical delivery for the rich and the poor is increasing. The Bhore Commission Report (1952), to reformat the medical and health systems, sought to fill the vacuum of trained doctors in rural areas. There was previously a licentiate system of medical practitioners (LMP) that provided valuable services to rural India. They underwent training in medical colleges and had an official degree to practise medicine, though in a limited manner. Unfortunately, the committee rejected this system in its entirety. Its core recommendation became a properly trained ‘basic doctor’ as the best person who, given adequate ancillary staff, can impact health delivery. Some solid recommendations, however, remained utopian, as we are still struggling with the health parameters. The load is now on tertiary-level hospitals, which are not able to cope. The Primary Health centres, visualised as the backbone, crumpled to their present degenerate state.
Rural India stays detached from the main hospitals in most instances. Ironically, the majority of Indian doctors stay in urban areas, catering to an urban population that may form only 20% of the Indian population. With a weakened primary health care system and poor transport facilities, health delivery in the villages has gone into the hands of quacks. Barely educated, they are smart people in the villages who have exploited fluid medical systems to make money.
There has been a recent move to introduce a system that allows untrained people, outside of the medical college curriculum (like in the past), to become trained as ‘community health providers’ who can practise preventive and primary medical care. This can be a dangerous and ill-conceived move to increase the doctor-patient ratio. A proper debate is essential to devising a method of training a group of ‘middle-level practitioners’ who would be useful and at the same time non-dangerous, addressing the biggest fear of concerned Indian doctors. It would be a far better idea to look for well-trained nurses to fill this need for primary health care. Their numbers are better than doctors, they are part of a structured curriculum, and they are an inherent part of the medical delivery system without any ambiguity.
Health does not depend only on the availability of doctors, drugs, and equipment. It depends greatly on the provision of clean water, good roads, the elimination of garbage, closed drainage systems, improved food and educational opportunities, and sterling transport services. The very act of covering our drainage systems would eliminate many of our health problems. But successive governments across the country have not done too well on these counts. The reasons are mainly faulty planning at the political-bureaucratic level, even as doctors take the blame for many of the ills plaguing the medical delivery systems.
SUICIDES IN THE MEDICAL PROFESSION
FEBRUARY 25, 2023
The suicide attempt of a young post-graduate pursuing anaesthesiology now battling for her life is unfortunate but more so is the huge politics now colouring the issue. For a start, the strict and sometimes harsh behaviour of a senior towards a junior during a medical residency program is almost a universal phenomenon. Most of the doctors go through this process of discipline and exposure to harsh remarks without fail and it is almost a normal part of their professional training. This is like the internal discipline in the armed forces training which to an outsider may appear highly brutal and almost inhuman. There are, of course, many understood limits but exceptions do exist where the limits may cross. However, such instances are extremely rare.
Suicide is a very serious issue and many times it is more about the individual rather than anything else. In a medical career of almost a decade starting from my MBBS entry to the end of my specialization, I saw almost a suicide each year which included my juniors, colleagues, and seniors. The routes of suicide were horrifyingly dissimilar and reasons were hugely varied but the problem in each case was that the person could not handle the stress of problems happening at a personal or professional level. The way forward of course is to constantly counsel the students and young populations to handle pressure and to make them strong to receive the setbacks of life. But pre-emptive measures to identify highly sensitive persons who will fall off the edge at a seemingly trivial trigger point appear difficult at present.
Hence, depressingly, as long as the human mind is in the present state of evolution, the negative aspects of society like crime, murder, rape, and suicides will stay though thankfully uncommon. There will perhaps be more stories of determination, will to succeed, and a fight against adverse circumstances. With extreme sympathy towards the young doctor battling her life the heart also goes out for the boy as what could be a simple open and shut case, whole new dimensions of group and religious identities enter the fray.
The cacophonous narratives of ‘love jihad’, ‘atrocity acts’, ‘minority victimhood’, and ‘religious protection’ will ensure that truth will have a burial. From the experience of a long medical career, it could simply be a case of personal and professional interaction gone horribly wrong without any connections to sexual harassment, caste, or religion. But let the agencies conduct their investigations in peace to know the truth. We are unfortunately living in an increasingly polarised society and hence issues which were never were important while tackling the problem of depression and suicide in the past are becoming prominent. The trial by media and the involvement of politics and group identities is sad to say the least.
THE DIFFICULTIES IN THE HEALTH SYSTEMS
OCTOBER 16, 2022
‘Managing rapid changes in the medical field’, a thought-provoking article in THI (16th October 2022), does not consider the doctor’s perspective at all unfortunately. Health consists of both individual health and societal health (public health). The latter is initially cost ridden but eventually reduces health care cost. We definitely need a health pyramid where doctors occupy a small space at the top. The broad base consists of measures like good roads, sanitation, covered drainage, mosquito control, a good water supply, and an effective organization of the health delivery system starting from the Primary Health Centers to the tertiary level hospitals. Specialists should indeed play a small role in both public and individual health. Unfortunately, in both private and public medicine, the pyramid has simply inverted.
The reasons for collapse of the public health system lie elsewhere which should ideally be a moment of introspection. The whip unfortunately falls on the doctors. Today, the pressures from ‘perfect and extensive’ documentation, excessive patient expectations, the insurance driven protocols at variance with rationality, the intense legal and media scrutiny, the excessive regulations (which surprisingly does not seem to exist for the unqualified quacks), and the readiness of society to violently hit the doctors when things go wrong, are all taking their toll on the doctors. The rot in the medical systems involves doctors, regulatory bodies, judiciary, press, politicians, administrators, bureaucrats, medical companies, drug policies, and the patients too. Greed, ambition, expectations, pressures, stresses, lethargy, inefficiency, and incompetency strikes each of the factors at varying levels. It is too simplistic and reductionist to blame the doctors alone in this situation.
TERMINATIONS-ETHICAL ISSUES
SEPTEMBER 30, 2022
The routine use of ultrasound and other machines in pregnancy management has allowed the diagnosis of many conditions in the foetus. The legal age for termination from 20 to 24 has certainly eased the pressure on medical practitioners dealing with many foetal anomalies where the window of 20 weeks was just too narrow for anybody’s comfort. In the west, political ideologies, religious affiliations, and socio-cultural factors (50% unwed mothers in the USA) all play a role in vigorous debates on terminations. The whole range of ethical, moral, social, and legal issues is presently complex and confusing. Two lives entangle as one unit and a clash sets up between the autonomy of a vociferous mother and the silence of the dependent foetus. Unfortunately, the idea and essence of motherhood disappears in the discourse even as foetal rights makes its entry. At the crux of western debates is the consideration of when does life begin? At conception, birth, or at some point in between? Some scholars interestingly propose a 24 weeks limit based on some research showing well-formed foetal brain waves ‘typical’ of humans declaring the transition of a fetus to a human. The Supreme Court seems to have come to that figure circuitously as the primary consideration was the safety of the mother while carrying the terminations. This is not the final word of course since the ethical and legal issues are going to only increase in the future as more diseases enter the domain of pre-delivery diagnosis, more newborns survive earlier stages of gestation, unwanted conceptions increase, and marriage becomes more disdainful.
DEMONIZING DOCTORS ON CAESARIAN SECTION
JUNE 22, 2022
The softest target in the country and the easiest to demonize has to be the medical profession. Caesarian Sections are the commonest means to do this. The political-bureaucratic pressure seems to have come hard on the Caesarian sections. A news item (THI dated 21st June) mentions the Collector proclaiming that thanks to the measures initiated by them, the Caesarian section rates have come down from 98% to 90% in private hospitals and from 77% to 67% in government hospitals. How ethical is it for the governments to concentrate on the technical aspects of individual surgeries when clearly, they are not qualified to do so? This, instead of focusing on the more important duty of providing health care access to all.
Without discounting commercial motives, most debates on Caesarian Section rates show a tunnel-vision. Some government teaching hospitals, where commercial motives do not perhaps stick, show CS rates of almost 80% and up. Caesarian Section is rising the world over: China (47%), Italy (36%), Australia (33%), United States of America (32.2%), UK (26%), and New Zealand (26%) are some examples. Also, the proportion of Caesarian Sections is increasing every year in all countries. Is India an exception (at 17.2% in 2015–16)? Yes, because it best meets the much quoted 10%-15% WHO criteria of an ‘ideal’ CS rate where less than 10% implies that the health standards for the country are poor and more than 15% implies unnecessary surgeries with risks outweighing benefits. However, these figures reflect something else too. Despite the ‘obviously evident’ high Caesarian Sections all around in the country, an overall figure of 17% points to pathetic health delivery standards of the country, averaging the country’s figure to such a respectable figure. It actually reflects poor healthcare access across the country. The governments should be highly reflecting about its own performance over decades based on these numbers.
The financial, legal, and technical reasons for CS increases are manifold: Increasing maternal age; increased numbers of multiple births; higher rates of obesity and Diabetes; medical-led view of pregnancy and birth leading to higher rates of interventions; fear of birth and labour pain; concerns about genital modifications after vaginal delivery; fear of medical litigation; low tolerance of anything less than the perfect birth outcome; Polycystic Ovarian Disease (PCOD) growing in epidemic proportions; infertility treatments leading to multiple gestations; increased incidence of big babies; increased incidence of abnormal pelvises in mothers; and so on. Cultural and horoscope considerations play an important role in countries like India and China.
Due to the complexity of all these scenarios and the interconnected factors, interventions to reduce unnecessary CS have only shown moderate success to date. The World Health Organization Statement, reiterated by the Indian Obstetrician’s body FOGSI, emphasizes that every effort should be to provide Caesarean Sections to women in need, rather than striving to achieve a specific rate. Even if charges for normal vaginal delivery become equal to Caesarian Section charges (as some suggest as a solution), it is highly doubtful that such a strategy would reduce the CS surgeries. The debate requires more nuance and not bias on the part of our intellectuals.
ONE SIDED DISCOURSE ON MENSTRUATION
MAY 28, 2022
Recently we celebrated Menstrual Hygiene Awareness Day. Menstruation is one of the most basic human physiological processes related to the propagation of our species. And it is fascinating that over thousands of years, a perfectly physiological process finds itself intricately linked with a whole set of cultural, social, and religious beliefs. The entire discourse of menstruation has now changed to that of hygiene and rights- purely biological, nothing sacred, nothing to be ashamed of, and nothing impure about it. In the social context, again the western paradigm of rights has taken over the narrative. The dealing of menstruation is a completely private affair with sanitary pads as a tool to declare equality by ‘not missing any action’. All spheres, including the commercial, focuses specifically on the twin issues of menstrual hygiene and independence.
As Nithin Sridhar details meticulously in his book, Menstruation Across Cultures, the social and cultural practices many times, go far beyond these straightforward modern narratives and it would be useful to understand some of them before condemning them outright. Anthropology is the study of human customs and beliefs; and which finally show us why we are humans. The two concepts of sacredness and impurity are the main issues which make menstrual understanding so interesting. In Hindu traditions, there are many deities and goddesses associated with fertility and menstruation. These deities are the manifestations of the primary Shakti. Hindu traditions clearly consider menstruation as a sacred and a positive process worthy of respect, worship, and even celebration. Unfortunately, nowadays the practices surrounding menarche and menstruation have strong negative connotations either by blind mechanical restrictions or completely throwing them off as taboos by the ill-informed families combined with a secular discourse in the environment.
The sacred aspect and the Asaucha are complementary- two sides of the same coin. This period of temporary state of impurity or ‘Asaucha’ is a time where the Rajasic energy is pent up in the body. This places certain temporary restrictions and lifestyle modifications which includes physical isolation from the rest of the house, avoidance of physical activities, avoidance of kitchen work, and abstinence from sex. These restrictions neither degrade women nor make them inferior by any stretch of the imagination. However, menstruation most importantly is a self-purification process at the physical, mental, and spiritual levels. There is no connotation of inferiority, degradation, or subjugation.
Yogic literature and Ayurveda look at menstruation as a physiological process deeply connected with the Vayus or forces in the body. The impurity aspect has more to do with a temporary state of heightened Rajasic energy and Dosha imbalances in the body, which needs countering by a period of physical and mental rest along with dietary modifications. The modern narrative regarding this practice has been consistently that of subjugation.
All the Abrahamic religions subscribe to the categories of purity-impurity and all of them have menstrual restrictions but the foundational principles are different. Menstruation in Hinduism is a state of heightened Rajas; in Abrahamic religions, it connects with Original Sin. Purity-impurity attaches to vitality and competence in Hinduism; whereas it associates with virtue and sin in the Abrahamic religions. These are some clashing elements between the Hindu and the Abrahamic view of menstruation. Greco-Romans, Mesopotamians, and the Egyptians of ancient times show many similarities to Hinduism with respect to the sacredness and purity/impurity of menstrual practices.
Menstrual practices across cultures have been an interesting phenomenon and to understand them fully is the need of the hour. The modern Hindu women pulled in opposite directions by the sacred traditions on the one hand and the contemporary scientific narrative on the other becomes confused even as courts deliver judgements related to religious issues based on ideas of gender discrimination. Unfortunately, the non-physical aspects have become ‘taboos’, reducing menstruation to negative notions of pains, cramps, and a hindrance in the way of progress. Now, the whole conversation of menstruation is hygiene and independence. Anything else is discrimination or sadly, a superstition.
DOCTORS SUICIDE AND CLOSURE OF HOSPITALS- DOCTORS AS SOFT TARGETS
APRIL 1, 2022
The softest target in the country and the easiest to demonize has to be the medical profession. This manifested clearly in the unfortunate suicide of Dr Archana Sharma and the recent closure of private hospitals in Nirmal district for allegedly performing excessive Caesarian sections. No other profession perhaps faces this form of intense scrutiny and backlashes from every member of society starting from the man on the road to the most educated person sitting in high offices. Expecting more may be a factor but a doctor would always aim for the best result and a prompt resolution of the patient’s agony. This is unlike any other profession in the public or private sectors where greed and corruption thrive on delivering incompetency, inefficiency, and unconcerned with a quick resolution of anybody’s agony.
Caesarian Sections are the commonest means to demonize the doctors. Without discounting commercial motives, most debates on Caesarian Section rates show a tunnel-vision in understanding the problem. Is there a serious statistical study to compare the CS rates in government and public hospitals? The numbers might reveal a different picture. Some government teaching hospitals, where commercial motives do not perhaps stick, show CS rates of almost 80% and up. The second issue is that the Caesarian Section is rising the world over, and India is no exception. Recent statistics from 150 countries show a global Caesarian Section rate of 18.6% of all births. China stands at 47%, Italy at 36%, Australia at 33%, and the United States of America at 32.2% to name a few. Canada, UK, and New Zealand have figures around 26%. Also, the proportion of Caesarian Sections is increasing every year in all countries.
The financial, legal, and technical reasons for such increases are manifold: Increasing maternal age; increased numbers of multiple births; higher rates of obesity and Diabetes; medical-led view of pregnancy and birth leading to higher rates of interventions; fear of birth and labour pain; concerns about genital modifications after vaginal delivery; fear of medical litigation; low tolerance of anything less than the perfect birth outcome; Polycystic Ovarian Disease (PCOD) growing in epidemic proportions; infertility treatments in the latter and other conditions leading to multiple gestations; increased incidence of big babies; increased incidence of abnormal pelvises in mothers (CPD or Cephalopelvic Disproportion); and so on. Cultural considerations and horoscope considerations also play an important role in specific contexts; common in countries like India and China. Considering solely medical factors in this complex scenario is likely to be a futile effort. Factors associated with women’s fears; and societal and cultural beliefs are very likely contributing to the increase. The reasons for increasing CS rates goes much beyond the simple binary of ‘greed or no greed’. Due to the complexity of all these scenarios and the interconnected factors, interventions to reduce unnecessary CS have only shown moderate success to date.
The much-quoted World Health Organization figure of 10%-15 % as the ideal Caesarian Section rate needs an Indian perspective as well. Apparently, less than 10% implies that the health standards for the country are poor and more than 15% implies unnecessary CS, with risks outweighing benefits. The USA has a CS rate around 35%; and India (17.2 % in 2015–16) looks better here. However, these figures reflect something else too. Despite the obviously evident high Caesarian Section rates above 50% (and sometimes touching 90%) all around in the country, an overall figure of 17% points to pathetic health delivery standards of the country, averaging the country’s figure to such a respectable figure. It reflects poor healthcare across the country. The governments should be highly reflecting about its own performance over decades based on these numbers.
The World Health Organization Statement, reiterated by the Indian Obstetrician’s body FOGSI, emphasizes that every effort should be to provide Caesarean Sections to women in need, rather than striving to achieve a specific rate. Even if charges for normal vaginal delivery become equal to Caesarian Section charges (as some suggest as a solution), it is highly doubtful that such a strategy would reduce the CS surgeries. The debate requires more nuance and not bias.
NEURAL TUBE DEFECTS, FOLIC ACID, AND PREVENTION STRATEGIES
FEBRUARY 2, 2022
NTDs (neural Tube Defects) are one of the most distressing conditions in a newborn child. Defects in the vertebral column and the spinal cord lead to a spectrum of disabilities which includes lower limb weakness and paralysis; loss of control of bladder and bowel movements; and accumulation of water in the brain (hydrocephalus). It would be a rare lucky child who does not have many neurological complications and who requires only a single surgery for correction. Most of them undergo multiple operations and almost a lifetime of care involving a multidisciplinary approach (Paediatric surgeons, Paediatricians, Neurologists, Neurosurgeons, Orthopaedic surgeons, Physiotherapists, Rehabilitation therapists, and so on). The physical, financial, emotional, and psychological burdens on the patient and the family are heavy beyond the imagination of a layperson and beyond a methodological calculation. In fact, so grave is the burden to the patient and the caregivers that it is almost a norm and an accepted protocol across the world to terminate the pregnancy if detected in the early part of the pregnancy.
At a very conservative estimate of 4.1 live births of this condition per 1000 births, almost 100,000 babies are born annually across India afflicted with Neural Tube Defects. To gain a perspective about the financial burden, the lifetime costs for a baby with NTD in the US is approximately $791,900 (translating into 5,85, 34,000 rupees per baby). Even if medical care costs are one hundredth of US in India, it still is a significant financial burden to the primary wage earner of the family. Dr Ravindra Vora and Dr Asok Antony, in a well-argued editorial (Journal of Indian Association of Paediatric Surgeons, January 2022) show a brilliant solution to this distressing problem.
It is amazing that many times the simplest reason is the root of the most complex problems. The cause of Neural Tube Defects is a deficiency of Folic acid in the mother during the time of conception. Worldwide, there is a confirmation of the fact that this humble vitamin given prophylactically to women planning to conceive reduces the risk of NTD to almost 80%. One of the best preventive programs would be to supplement folic acid to women of child bearing age. The US tried first by recommending and supplying this in tablet form but poor compliance led to the policy of fortifying wheat flour with the correct dose of folic acid. The annual rate of NTDs came drastically down.
Authors Dr Vora and Dr Antony suggest a simple but practical solution in India. Differences in eating practices and methods of procuring the food material would make a central fortification scheme difficult for women in the remote villages. They suggest fortifying tea, commonly used across India, and generally with central production distributed peripherally, with folic acid and Vitamin B12, both found deficient in Indian women of child bearing age. Interestingly, this deficiency is irrespective of the food habits. The Indian non-vegetarian food is ‘near’ vegetarian, in fact, the authors write. This is perhaps a simple and safe solution to an extremely difficult problem taking a heavy toll on the afflicted patient, the families, the healthcare professionals, and the governments too. In their pilot studies, they have found this method to be extremely effective in Maharashtra. Though the authors are communicating with the central planning agencies and the tea boards to make this feasible, it is perfectly possible for individual state governments to start the program on a smaller and more manageable scale. It would also be a great idea if tea marketing and mainstream advertising incorporates this idea of supplying tea bags fortified with folic acid and Vitamin B12 specifically targeting potential mothers.
It would be a sincere request for the media and the honourable health minister of our State to seriously consider this proposal of tea fortification and take it forward in what could be a cheap and effective preventive strategy. The vitamins are non-toxic in the doses recommended and being water soluble, the kidneys handle any excess by simply throwing it out in urine.
MICROCOSMOS AND PANICS AT VIRAL MUTANTS
DECEMBER 3, 2021
It is a characteristic human trait to create panic at the slightest hint of a threat as the new variant of Omicron amply demonstrates. Humans look at the microworld composed of bacteria and viruses as essentially hostile, threatening their survival. The fight is always ‘on’ to suppress them and keep the humans at the top of the evolution charts. Nothing can be more foolish than this false sense of being at the pinnacle of evolution starting with the ‘lowly’ bacteria at the bottom as Lynn Marguilis and Dorion Sagan show in their fantastic book, ‘Microcosmos’. The microcosmos has been around for almost 4 billion years and are likely to go on for billions more. The horizontal transmission and mixing of genes are responsible for almost an infinite immortality of the species. The individual bacteria may divide but collectively, it is forever living. In fact, the rapid transfer of genetic material across the entire species almost calls for a definition of a global ‘super-organism’ instead of single units. Humans are perhaps one small way of spreading viruses or bacteria. They can do very well on their own without requiring human agency.
Constantly fed on the Darwinian concept of ‘survival of the fittest’, we are simply not aware, as Lynn Marguilis points out, that symbiosis too is a very important process in evolution. Life is a complicated web of interactions. The amazing fact of the human body is that only 10% of all our trillions of cells are ‘human’; 90% are bacterial cells. Not only that, the mitochondria in each cell are a foreign bacterium incorporated into all the eukaryotic cells at some remote time in the past and helped in the utilisation of oxygen. Similarly, the chloroplasts in plant cells, vital in photosynthesis, is in all probability an incorporated bacterial DNA. Today, life depends on the ability to utilise oxygen, the most important source of which is plant life. An interesting speculation is consciousness itself may be because of the quantum jiggling of microtubules in the brain which in turn may be of spirochaetal origin! It is a humbling thought.
So, there is an entire paradigm shift from competition to co-operation in the process of evolution. Survival in strict Darwinian terms is fecundity, that is the amount of progeny one produces. In this regard, humans are distinctly at a disadvantage. The most rapid reproduction is in the bacteria which divide once every 20 minutes and the rapid exchange of DNA in a horizontal method ensures almost a super-organism spread across the globe. Viruses are not as hostile to the bacterial world as they are perhaps to the human cell. There are also some ideas theorizing that a major part of human DNA might be viral DNA incorporated again at different times in a remote past benefitting both the human body and the virus in a symbiotic relationship. The only thing which is popular about human reproduction is that it happens to be pleasurable, but apart from that, there are no survival advantages in the human mode of reproduction.
Anyway, the important thing is that can we be effective in really stopping the spread of viral and bacterial mutations by putative measures like travel restrictions? How much would a strategy of ‘complete elimination’, if such is ever possible, really going to help in our survival when ‘we’ are by ‘them’ mostly? The point is that bacteria and viruses have been mutating for billions of years and that is how they have survived and will survive long after we are gone. We should seek solutions to stay in harmony instead of making the entire microworld into a rogue nation. Panic at every detected mutation is perhaps a wrong way to deal with our survival.
THIN IS BEAUTIFUL
OCTOBER 30.2021
I recently saw a wonderful English movie where a fat girl enters a beauty contest and faces many problems, mainly disbelief, from all around. The mother, who is a previous winner of a similar contest, is shocked that her daughter even thinks of entering the contest. It is unfortunate that being thin has become such a normative ideal. Many people, especially the growing children, do not confirm this and are fat for many reasons. There are many factors involved and it is not a simple equation of excess diet added to a lack of exercise. The advertisements, brandings, models, movies, celebrities, and the society almost bombards on a constant basis that being thin and fair is the only way to be beautiful. What would explain celebrities endorsing fairness creams and slimming agencies? The whole society stacks against many young growing minds with this propagation of what beauty is as per normative standards. Is it really a responsible society? A healthy society and a healthy individual are what we are seeking. It is important to understand the difference between ‘being fit’ and ‘being healthy’. One can be extremely fit and yet be having major blocks in the blood supply of the heart. There have been many cases of athletes and fit individuals who have collapsed suddenly. It is true that sedentary lifestyles, excessive indulgence in digital devices, unhealthy eating habits, and easy access to junk foods by a click on the app, are all responsible for causing problems of obesity and overweight. There is an urgent need to address these issues on a larger scale where everyone in the society needs to get involved one way or the other. However, it needs a massive readjustment at many levels to stress that being beautiful is not being thin and fair. We need a shift from the message, ‘Beauty is Fitness and a Fair Tone’ to perhaps ‘Health is Beauty.’
VIRUSES AND VACCINATION
JUNE 15, 2021
The debate on vaccination is always confusing. It has been so since many decades. Vaccination against small pox was known to Indians in pre-colonial times as Dharmpal so emphatically shows. Traditional vaids were using material from the small pox patients for vaccination. Amazingly, the concept of immunisation was in place in Indian society in the era much before Jenner.
Most viral illnesses have a resolution rate of more than 90% without any interventions. This explains the success of many interventions in the treatment of viral diseases, like for example, many herbal products and local popular concoctions for the treatment of hepatitis.
Secondly, vaccinations are never a foolproof guarantee against the occurrence of the concerned disease. The best protection rate is in the range of 70-75% perhaps. BCG for TB for example doesn’t have any great protection rates for primary lung disease though it works better for TB involving other organs like the nervous system.
Modern vaccination has always had a chequered history. Right from the beginning, injection of many vaccines into the human body in the first year of life administered along with many additives and preservatives has been a source of intense concern and debate. Autism, diabetes mellitus, autoimmune disorders have all been claimed to be associated with vaccination. The vaccine promoters and a majority of paediatricians say ‘no evidence’; the anti-vacciners say the jury is still out.
The first-generation rotavirus vaccination had lot of issues with intussusception in children, a real surgical problem. There was a 30-fold increase in the likelihood of intussusception. The later generations of this vaccine have a lower risk.
Any vaccine company wants only one dream situation and that is an official government policy to vaccinate the general population with that particular vaccine. This is the loveliest dream come true for any company to make for a massive kill in terms of business and healthy balance sheets.
Unfortunately, in a pandemic scenario where we are trying so many things it is expected that there would be attention to vaccines too. The background debate however against vaccines is nothing new despite being in extraordinary circumstances. This is perhaps the only time in the history of medicine where we are trying to develop vaccines and treatment strategies in the middle of a pandemic caused by an unknown virus.
Beyond the oft repeated and standard narratives of greedy companies and bad governmental policies, the fact is, nobody knows the full picture. Many are desperately shooting in the dark. We don’t know about the nature of the virus; we don’t know about the natural history of the disease; we are not aware of any standard treatment strategies. Hence, the multiplicity of approaches to this natural or human made virus.
The human brain will keep on trying solutions to any problem. Like always in the history of humanity, complex political, social, and economic factors; personal issues; and emotional reasonings will distort a straightforward scientific or medical narrative. It is indeed a complex and messy situation with no straightforward answers.
The present debate will never end as there are no ideal solutions excepting that the virus becomes completely quiescent; integrates into the human genome; or we develop a magic bullet like a quinine or chloroquine for malaria. Some scientists say that a great portion of human DNA might actually be of viral origin which got integrated nicely as a symbiotic relationship.
Unfortunately, with an explosion of knowledge and an easy access to information, we are getting all the more confused with the information. Extreme positions look at the worst of the opposite camp to justify their stands. The anti-people would only look at the small but real complications of vaccines. The pro- people would quote the complications and deaths in the unvaccinated group.
We cannot get a balance and a golden mean within such polarised debates unfortunately. The solutions are never easy and they keep changing with evidence. Changing practices with evidence does not mean a deficiency; it is only scientific and healthy practice. Unfortunately, ill-informed intellectuals make ridiculous statements which go against the tenets of medical philosophy. Irrationality rules supreme in making many speculations which our media are only too keen to propagate. The poor citizens pay a heavy price with the added scare and fear.
SLAPPING NOTICES ON CORPORATE HOSPITALS: GREED, RATIONALITY, AND ETHICS IN MEDICINE
MAY 28, 2021
Autonomy (for the patient), justice (ensuring availability to all), beneficence (only for the good of the patient), and non-maleficence (not causing harm to individual or society) are the four basic principles of health care ethics. At the core of health ethics is the sense of right and wrong; and beliefs about rights and duties. Like all domains, ethics and morals are fluid and debatable with even cultural differences too. What is moral or ethical in one culture may not be so in another one. Ethics is dynamic. What was good ethics a hundred years ago may not be so today. Despite many controversies and discussions on the above four principles, most agree that patient autonomy is by far the most important overriding all the other considerations in event of a clash.
There are rights and duties of the doctor and there are rights and duties for the patient too. Unfortunately, the entire discourse of the governments, media, and the intelligentsia focuses on the duties of the doctor and the rights of the patient. In this process, a heartburn ensues which finally damages the profession.
Medicine, like many other professions, is a fine balance of art and science. Somebody in a malaria endemic area may choose to start anti-malarials for a fever with chills. There might be another doctor who would want an investigation to confirm malaria before starting treatment. Both are perhaps correct and cannot undergo comparison in the binaries of ‘non-academic/ academic’ or ‘non-commercial/commercial.’ The conflicts doctors encounter in the profession many times are complex beyond the understanding of even other non-involved doctors, not to mention the laypeople.
There is a list of many do and don’ts for the doctors divided as compulsory duties, voluntary duties, unethical acts, and misconduct. There are some we are quite aware of as it makes a lot of noise in the media. Some are more subtle. The unethical acts include advertising, printing a self-photograph on the letterhead, commissions, euthanasia, and so on. Misconduct includes sex determination tests, not maintaining records, and disclosing secrets, amongst many others. Active euthanasia is thankfully not a big debate issue in India as in some western countries.
Significantly, there are no guidelines on what should be the ideal charging for the patient. There might be official bureaucratic orders to display the consultation charges or the charges of various services provided in the hospital. However, the ethical guidelines provided by the medical council do not address the charges for services in the non-public sector at an individual or institutional level.
In terms of legal attacks, governmental regulations, and popular perception, the majority of the medical private sector has come in the ambit of a business model. Thus, there is an inherent and fundamental contradiction between the service model and the business model in our medical systems. The patient in a private hospital expects the best possible services but at the most reasonable charges. How is this balance decided? How can one calculate the rational pricing when an expert surgeon saves the life of an individual? Why should capping be applicable only to the medical sector? The business proposition seriously mixes with humanitarian considerations in medicine and this is the main reason there is so much debate in society. Consumer protection and legal questions stay intact making the doctor always vulnerable in case of adverse outcomes. The art of medicine loses out in legal battles as the focus becomes only the guidelines and scientificity.
One goes to a five-star hotel and pays twenty times more than the nice hotel in the neighbourhood for the same idli. An individual or institute approaching a top-shot private lawyer would grumble but would happily pay a Himalayan amount of money for the services rendered. There is a choice available to the person. The reason for dissatisfaction and heartburn in society happens because poor patients and uninsured patients forcibly go to the private sector instead of utilising the public sector.
This lack of choice should make our thinkers reflect on the state of the public services in the country or the lack of proper and rational insurance policies. Ironically, the government insurance schemes for the public sector are so poorly structured that there is enormous hesitation to take up difficult cases and generate a whole set of practices which ultimately does not benefit the health of the individual or the society. Similarly, attacking individual doctors or slapping notices on corporate hospitals for being greedy is a short-term populist method of solving issues.
When the capping comes for private institutes in the health sector, what should be the limits? To what extent business practices apply to the medical sector? The point is, these are difficult issues and there is certainly a need for wide debate instead of unthinking reactions which can only harden stances. Ethics and morals are a very difficult subject, especially in the practice of medicine. Rationalising any unethical practice (on part of the doctors) and outright condemnation of any practice (not fitting into popular common-sense perceptions) are both wrong; and there should be perhaps an attempt to achieve a balance. The public-private model of health should deliver the goods to all the citizens of India in an effective manner without physical or intellectual violence in society. Is there hope for such a debate?
ABORTION- DIFFERENT PERSPECTIVES IN DIFFERENT CULTURES AND TIMES
MAY 25, 2021
The editorial on 25th May, ‘Abortion still a raging issue in US’, wonderfully highlights a relevant topic where politics, society, law, medicine, ethics, morals, religions, and human rights make for a complex cocktail of raging emotions, disparate voices, and fights of all kinds. A consensus statement is unlikely anytime soon. Essentially, the debate is regarding a contradiction between the two fundamental properties of a liberal life: the freedom to choose and the right to live.
The so-called right wing (pro-life or no right to abort) and the so-called left wing (pro-choice or right to abort) take hard stances across a clear dividing line. Religious denomination also comes into fray. The Catholic Church do not support abortion categorically at any stage of pregnancy. Protestant Churches have a variable stand on the issue ranging from opposition to complete support. Compromise seems hardly possible as offense comes easily with any stance. This indeed is a serious issue in the West, especially the US.
The famous Roe v. Wade case changed American law on abortion. The legal guidelines for terminating a pregnancy is a pragmatic view and not on any moral, ethical, or religious ideas. The right to live (for the fetus) is the consideration in the latter part of pregnancy and the freedom to choose (for the mother) in the early part. The US courts do not address the slippery slopes when each of the arguments goes to the extreme and demands either the freedom to choose or the right to live in all stages of pregnancy.
The US Supreme Court does not consider in the abortion debate whether human life or personhood begins at conception, birth, or at some point in between. The 24 weeks guideline is on the ‘survivability’ of the fetus outside the womb and specifically, the lung maturity to take independent breaths. Scientist Carl Sagan concurs with 24 weeks but for different reasons. Research is pointing out that at 24 weeks the fetal brain starts showing well-formed brain waves typical of a human being and that might declare the transition of a fetus to a ‘human’, he says.
Carl Sagan puts two questions here. First, why should breathing only justify legal protection? If one shows that a fetus can think and feel but not be able to breathe, would it be all right to kill it? Second, with improving technology, a fetus might survive much earlier gestational ages. If available in a possible future, does it then become immoral to abort earlier than the sixth month, when previously it was moral? Sagan says, ‘a morality that depends on, and changes with, technology is a fragile morality; for some, it is also an unacceptable morality.’
The Indian MTP act, formulated in 1971, made the legal limit to 20 weeks purely on the consideration that after this age, terminations can be unsafe for the mother. The discrepancy in the Indian rules arises from three considerations. First, termination is now safe even at later stages of pregnancy but the rule has seen an extreme resistance for updating based solely on this safety criteria. Second, many fetal anomalies, some serious and difficult, in the Indian scenario have a diagnosis between 20 to 24 weeks with the application of the latest in the field of antenatal testing including genetic analysis. This puts a severe stress on the doctors and the affected families both when there is potential confrontation with the law. Third, the conflation of the MTP Act (for safe and legal abortions) and the PC&PNDT Act (to prevent gender based selective abortions) has many implications on access to safe abortion services for women.
Nitin Sridhar (Abortion, A Dharmic Perspective) using extensive ancient Indic sources (Dharmashastras) shows how ancient Indians set the limit for legal abortion at 16 weeks but with a different reasoning. Taking the notions of the individual Jiva, Karma, Dharma, Adharma, and Prayashchitta into consideration, Dharmic texts perceive abortion as Adharma since, it prevents a Jiva from taking a physical birth, an entitlement based on Prarabdha Karma.
The Dharmic texts enunciate that though the Jiva associates with the fetus at conception, it enters the Hrdaya of the fetus only towards the fourth month of pregnancy. Thus, only the abortion performed after the 16 weeks of pregnancy is like killing a person, while abortion before 16 weeks is preventing Jiva from self-identifying with the fetus. Abortion after 16 weeks involved legal punishments and abortion before 16 weeks involved a Prayashchitta (a voluntary imposition for repentance) procedure for 12 years. However, the texts clearly say that after 16 weeks termination is acceptable without Adharma only if the purpose is to save the mother’s life.
Can we evolve a sustaining contemporary narrative and law on abortion based on the eternal principles enunciated in the Dharmic texts? The texts are not morally obligatory or legally binding as the colonials drilled into our collective minds. Intellectuals can always make better laws based on our Dharmic philosophy conducive to all but have we travelled too far on a ship of modernity which looks at tradition with only disdain?
BABA RAMDEV AND THE IMA
MAY 23, 2021
Baba Ramdev makes a public statement against allopathic drugs for Covid and the outraged Indian Medical Association slaps a legal notice on him. The governments and the public fall into a trap of an unnecessary debate between tradition versus modernity; obscurantism versus scientificity, and so on. Poet Alexander Pope says, ‘A little knowledge is a dangerous thing’ and this applies well to both sides. A little knowledge regarding the ‘other’ system generates ignorance and stupidity in ample proportions.
Ayurveda, in its fundamental belief that nature is the cause and cure of diseases, bases itself on the Tridosha theory of human disease which postulates an imbalance of Vata (air and space), Pitta (fire), and Kapha (water and gross matter) elements of the human body. Interventions of any kind seek to restore the balance. It understands the human body from a different domain level. The atomic theory and the germ theory of disease is the basis of modern medicine.
The paradigms of studying health and disease are different in Ayurveda and allopathic medicine but both have the interest of the human being at its core. Ayurveda, as a system of medicine, goes deep into physiology, anatomy, and observational studies of diseases, equally scientific and equally rational. Before the atomic theory of matter and the germ theory of diseases, dating just a couple of centuries, for thousands of years the Ayurvedic understanding of health and disease gave us many stupendous contributions in the preventive and therapeutic fields including plastic surgical techniques and vaccination against small-pox. It is a colonial mindset and a constantly west looking mind which would denigrate Ayurveda as a form of medicine. The reverse holds true too when there is a mindless criticism of allopathic medicine.
The principles of Sattvic diet, Yoga, Pranayama, and meditation form a crucial component of preventive medicine in Ayurveda. Modern medicine looks at psycho-somatic problems increasingly seriously, but this mind-body connection deeply embeds into the Ayurvedic framework. Meditation and deep breathing are vital in the mental and emotional well-being and solutions to many psycho-somatic illnesses. Dean Ornish (Reversal of Heart Disease) makes a compelling evidence-based argument for his program of integrating Indian Yogic exercises, breathing techniques, meditation, and diet to reverse heart disease. Most interventions-aspirin, medicines, stents, and surgery, at best halt the progression of disease, rarely do they reverse.
The either/ or approach is a modern scientific philosophy which either calls for either complete acceptance or a complete rejection. Extreme claims by Ayurvedic practitioners without careful studies unfortunately tend to make light of its achievements and strengths. There is no point in belittling Ayurveda in the lens of modern medicine or modern chemistry. One paradigm cannot be a yardstick to measure the other.
Baba Ramdev has successfully converted Ayurvedic techniques and products into a huge business proposition but he goes overboard in his criticism of modern medicine. Unfortunately, an equal imbalance and intolerance characterises the other party too. The criticisms arise from one’s own sense of power and poor understanding of the other side. In this clash, the powerful proponents end up making a show-piece of the worst of the other side. Harmony and integration have a quick death. In the bargain, there is only confusion and mayhem on the part of the ordinary people who only seek solutions to their health issues.
RANDOM MUSINGS 