The Kylie Factor

Kylie Minogue, the sultry Australian pop singer and actress, was detected to have breast cancer at the age of 37. The diagnosis forced this  international celebrity to put an end to her Showgirl Tour and career. She underwent breast surgery in Melbourne in May 2005, followed by chemotherapy in France. What makes her so special is the way she underwent treatment for her disease under intense public gaze, and the openness with which she shared her experience with her fans and the public.  She is back on track in her career, where she is flying even higher than before.

            Voted “Woman of the Year” in 2006 because of her inspirational fight against the disease, Kylie helped create a wave of awareness amongst fans and public about breast cancer. It led to a spike in screening tests in women. Described as the “Kylie Factor”, 40% more women underwent mammography and other tests as part of a cancer detection check up.

            Breast cancer is the commonest cancer in women in developed countries, afflicting one of every 8. It is the 2^nd commonest cancer (cancer cervix being the most common) in India, and is estimated to occur in one of every 22 women. Around 80,000 women are diagnosed with this condition in India every year. It usually occurs in the 4^th to 7^th decade, but may occur in younger age, as was the case with Kylie Minogue. Women with a family history of breast or uterine cancer, those who have not borne babies and Parsis are at high risk.  Mutation of the genes (BRCA1 and BRCA2) accounts for the development of this cancer in a significant proportion of cases.

            Breast cancer is curable if diagnosed at an early stage, when it is usually painless. This underscores the need for greater awareness in women. It can be picked up by regular routine self examination of the breast and a mammography test in those above 45.  Treatment consists of removal of the small lump by surgery, followed by some medications. The breast does not always have to be removed fully, or can be reconstructed for cosmesis.

            Treatment is more difficult if the disease is diagnosed at an advanced stage, especially when it has spread to other parts of the body. Surgery, even extensive, may not succed in removing the entire tumour and chemotherapy may not be able to kill all the cancer cells. The outcome in this setting remains somewhat grim.

            Kylie had likened her cancer battle as “experiencing a nuclear bomb”, but has fought and won it with grit and determination. As a pop legend, she has sold more than 60 million records. She has, however, become immortal in creating awareness about breast cancer in women.

As published in HT City, Hindustan Times dated 26 july , 2009.

Mosquitoes are Back!

The only silver lining I could see to the recent dry hot spell was respite from the droning and stings of blood sucking mosquitoes. Now that the monsoons have finally arrived, mosquitoes and malaria cannot be far behind.

                These little “animals” can be deadly; 40 million people suffered from mosquito diseases last year in India of whom malaria comprised 2 million. Of 247 million people who suffered from this disease globally (2006 data), 8 lac died, 85% being children, amounting to 2000 children dying each day. The other diseases spread by mosquitoes include Dengue fever, encephalitis, Chickungunya, filariasis and yellow fever.The number is increasing due to deteriorating health systems, growing resistance to drugs and pesticides, and climate change.

                There are 2 tragic aspects to the story of malaria: first, most who succumb to the illness do so because of delay in treatment, and second, malaria is not difficult to prevent as most developed countries have shown.

                Research in Africa revealed that during outbreaks of malaria, lives were lost largely due to delay. It took few days for a febrile person to consult a doctor, go through blood tests for malaria, and then receive medications for the infection.By providing anti-malarials emperically through a network of paramedics, to anyone having fever, many lives could be saved. Our experience in India is similar: many who reach us in their terminal stages have often been febrile for several days, seeing several doctors, travelling many miles, but not getting a dose of anti-malarials. The test results often come in a few hours too late.Treatment delayed is treatment denied!!

                How can we prevent malaria?  The female Anophelese mosquito can fly only a few hundred meters, needs a drink of human blood ( during which it transmits the malaria germs) and lays its eggs in water. If stagnant water from flower pots, coolers, buckets etc are drained and kept clean in the house and vicinity, mosquitoes can’t breed. A major problem today is water collecting in polythene bags thrown on the roadside or stagnant drains choked with them. Local community groups can help clean these up. Periodic fogging with Malathion and pouring kerosene in stagnant ditches usually require some help from the government. Mosquito nets and repellents (coils, mats or creams) form our last but least effective defence. Concerted action aimed at keeping the locality clean is far more beneficial than individual protection.

                Mosquitoes have played their role in history.  They delayed the construction of the Suez and Panama canals by striking many workers with malaria and yellow fever, and brought many mighty people to their knees (Alexander the great, and recently the thespian Dilip Kumar). Wise rulers of the Mohenjodaro days ensured that water in the canals they built kept flowing, preventing mosquitoes from breeding, and the Gates Foundation has identified malaria as one of its 4 thrust areas for support.

                The rains have come. Can we prepare ourselves better than the mosquitoes this year?

     As published in HT City ( Hindustan Times) dated 19 july, 2009.           

What is your BMI ?

One of the major challenges to remaining healthy in modern times is maintaining a “normal” body weight. Obviously, no weight can be considered normal and “fit all” for everyone. Health specialists are engaged in research and debate as to what is “normal body weight”.

The answer came from health insurance data, which showed that people who weighed more than they ought to have for their height, had more health problems and died earlier. The challenge was to define what was “over weight”.

Body mass index (BMI) is the commonest measure used across the globe. It is calculated by dividing your weight (in Kg) by your height in meters, squared. To use a simple formula: Weight (kg)/ height (m) ². For those who are poor in maths, you can read off your BMI on the charts, once you know your height and weight (whathealth.com/bmi/chart-metric.html)

The normal BMI range in western people is 19 to 25. A person with BMI between 25 and 29 is  overweight, between 30-35 as obese, between 35-40 as severely obese and above 40 as morbidly obese. What these figures indicate is that the higher the BMI climbs above normal, the risk to life and complcations go up in quantum steps. Researchers from AIIMS and ICMR have shown that the criteria for Indians need to be lower; a BMI above 23.5 is overweight, and above 28.5 obese. These limits were determined based on the increased risk of heart disease that was found in people whose BMI crossed 23.5!

Weighing more than one should is emerging as a major risk factor in urban Indians. The risk of developing diabetes, high BP, heart disease, fatty liver disease, joint problems go up. Obese people are unable to withstand stress and succumb easily. The life span is considerably shortened in obese people; they live 7 -14 years less than their normal weighing counterparts.

Some scientists feel that the pattern of distribution of fat in the body is more important for health than the weight. For instance, the weight may be high due to heavy bones but the person may be quite lean, or, a person may look and weigh normal but may have a ponch where excess fat is stored. Hence abdominal girth of more than 90 cm for men and 85 cm for women is considered as visceral obesity and confers risk to health. If your trouser waist size is more than 32” for women and 34 cm for men, watch out!

Milder degrees of obesity is best managed by cutting down on calories in your diet; avoid fatty food, pastries, sweets, soft drinks, pizzas and chips and increase the proportion of soups, green veggies and fruits in diet. Be regular with a good arerobic workout, such as jogging, cycling, swimming, dancing or walking for atleast 40 minutes a day, 5 days a week. If your BMI is over 35 you will need special help, especially if you suffer from diabetes or heart disease. Some of the medicines available in the market could help. If your BMI crosses 40 and if you are unable to bring it down, bariatric surgery could restore your figure and ensure that you live well and long.

 As published in HT City ( Hindustan Times) 

MJ 's death: Role of pain killers

The recent shocking death of the pop icon Michael Jackson at just 52 years , has drawn attention to the dangers of pain killer drugs. The autopsy report, just out, ruled out blockage of the arteries of his heart, and pointed to consumption of excess amounts of pain killer and other medications as the cause of his collapse. Reports suggest that he was on to as many as 7 drugs, comprising painkillers, muscle relaxants and anti-depressants, that made a deadly cocktail.

                 Pain killers or analgesics, are of 2 broad groups:

·         Narcotic: such as morphine, extracted from opium a product of the Poppy plant, or its “cousins” such as Pethidine (Demerol*), Hydromorphone (Dilaudid*, considered 8 times more potent than pethidine), codeine (Vicodine*), oxycodone, tramadol, pentazocine and others.  These are strong analgesics used for severe pain and have potentially serious side effects such as drowsiness, coma, respiratory failure, circulatory failure, shock and heart failure, apart from the strong potential for addiction and dependence. Many , such as pethidine, can be taken only as injections.

·         Non-narcotics: such as pracetamol (as in Crocin or Tylenol), aspirin, ibuprofen (as in Brufen), piroxicam (as in Pirox), and nimesulide (withdrawn from most countries). The commonest problem with these drugs is irritation and bleeding from the stomach.  They can also affect the liver and kidneys, but are not addictive and do not suppress breathing.

Apart from these side effects, pain killers can cross react with each other as well as with a large number of other medications. Hence “cocktails” are hazardous, as was with MJ.

                In addition, MJ was on alprazolam (a sleeping pill as in Alprax, Trika etc), chlorpheniramine (anti-allergic, that can also cause drowsiness), and on 2 anti-depressants, sertraline (as in Serta, Daxid) and paroxitine (Paxil), that added to the toxicity.  What probably precipitated his collapse was an injection of propofol, a drug that is used for general anesthesia; it causes total loss of consciousness and depresses breathing, and hence is supposed to be used only by anesthestists in a hospital set-up where artificial ventilatory support is available.

                Most of the narcotic analgesics are not available “over the counter”. How MJ had access to 3 of them (marked*) is not clear. What is most intriguing is how he managed to get his doctor to administer an intravenous dose of propofol, at his home!

                Irrational decisions are often taken by a depressed and confused mind. MJ was undoubtedly suffereing from depression and anxiety for which he was on medications. His financial losses and loneliness must have added to his frustration.  He was probably addicted to narcotics for quite some time, as the several injection marks on his body would suggest.  While the electrifying music of this musical genius will live on for many years, the story of his death should alert and remind us of the hazards of indiscrimate use of painkillers.

 As published inHT City Hindustan Times dated 5 july , 2009.

A Doctor's Pride and Shame

It is with mixed feelings that I look back to the summer of 1973 when I had to choose between medicine, engineering or English from the career basket of that time. The last 35 years have been a roller coaster ride of immense pride and intense shame.

It is a matter of pride that the life expectancy of Indians has increased to 65 years from the 34 in pre-independent times. I also feel proud that infections, easily treated with antibiotics, have stopped being the leading cause of death, at least in urban India (63% deaths are now due to life style diseases!). Small pox has finally gone from the world (we used see households die of this infection in the early 70s), and polio is on its way out. Children seldom die of tetanus, measles, whooping cough and diphtheria, these days, thanks to our immunization programme. Also, a variety of interventions for diseases caused by choked arteries, tumours, eroded joints, obstructing stones in the gallbladder or kidneys can now be treated with safety and ease. Medical science has indeed become a saviour.

            I feel ashamed when I read reports of my brethren turning killers: making more than a living by killing helpless innocent female infants even before they are born, and developing biological weapons that can kill innocent people. Many of the best medical minds in Hitler’s regime designed innovative ways to kill Jews, researching on how to kill more in less time. The potential misuse of euthanasia in the hands of some doctors will therefore remain a perpetual threat.

            The medical profession, that I know, embodies the “e”s of ethics and empathy. In moments of confusion the patient turned with complete faith to the benevolent doctor, not always for potions or cures, but for sound ethical advice. If Dr Binayak Sen was charged by the government for aiding terrorists, the world hailed him as a massiah who stood by his marginalized patients and refused to betray them.  He did the profession proud.

            I hang my head in shame when doctors go on flash strikes, oblivious of the faith and expectations of patients who had come knocking to their hospital door in desparate need of help, (that there was a goof-up by the “babu” in the secretariat, does not exonerate us of betraying our patients), when reports accuse us of ordering unnecessary expensive tests for monetary “cuts”,  when my brethren turn a blind eye to exanguinating  patients or accident victims, and  fearing legal hassles, prefer to let them die, or, when  kidneys are bought and sold in well regulated medical markets. Where has empathy evaporated?

            And medicine is not all service and dedication any more. It is a contract between customers (treatment seekers), and the health providers (doctor or hospital), covered under the legal umbrage of COPRA. And hospitals are good business ventures, with 5 star hospitals making good money treating the sick.

            Decades back, doctors had few medicines, few gadgets but plenty of respect. We now have hospitals resembeling shopping malls, a maze of hi-tec equipment, a bulging pharmacy, but scant and dwindling respect.  The medical profession could do well to try and regain its nobility.

As published in Hindustan times dated 2 july, 2009.

Indian Scientists - Hurdles

              Why Indian scientists working in India do not get the Nobel Prize:

1.       Nobel Prize is about excellence and newness, discovering something not already known.  While India has the largest scientific man power, the emphasis is not on excellence and new discovery. It is on doing science at the middle and lower levels, or in its application.

2.       Why is it not about excellence and discovery in India? 

Because excellence and advancing the cutting edge of science need the right climate and years of nurturing.  Accomplished scietists are not produced in a short period. They are bred, groomed and nurtured in an atmosphere where scientific pusuit is all that seems to matter. And they feel comfortable sacrificing everything else to pursue it.

3.       It is not by chance that many Nobel Prize winners hail from few universities like Harvard (USA), Cambridge (UK) and Gottingen (Germany). It has taken decades and centuries for these centers to become hubs of scientific pursuit. The best scientists work here, teach here and bring up and  inspire the next generation to come up and match their high standards, and go beyond. Scientists are well paid (in Germany, they are among the best paid), feel secure in pursuing science as there are enough opportunities in this profession. Contrast this with Indian scientists in premiere institutions like IITs or IISc, where committed scientists and teachers have to go on hunger strikes to get decent financial returns that would keep them there. Many would soon move to greener finacial pastures in industry or go overseas. The climate in India is certainly not conducive to high end research.

4.       In India, we often confuse merit with seniority and the perks that go with it. A brilliant scientist may be at the bottom of the ladder, is crippled with beaurocratic hurdles and has to struggle for every grant, equipment and chemical. His opportunities to excahnge ideas with international experts are often severely restricted or not available. His mind then starts wandering from the cutting edge of science to more immediately rewarding issues such as promotions, pay, perks, contacts with people in power and opprtunities else where. The single minded pursuit of science is therefore gone.

5.       Do we really need cutting edge research in India?  Basic science research is often open ended, where it is difficult to speculate what one might find, when, and what might be the implications of the finding. Organizations and labs must have deep pockets and long horizons to fund such research. All such research does not often end up in major breakthrough discoveries. But some do, and they often change the world. In India most politicians, administrators and science organizations do not often back such research where the goals are very distant and uncertain. We look for close ended research that will provide quick returns. These are not often the conceptually revolutioning discoveries that Nobel prizes are awarded for.

 As published in HT City ( Hindustan Times)