Teaching and Learning – is there a trick?

One of the big mistakes that we as parents and teachers often make, and that could stifle the mental development of our children, is to treat them as just small adults! In fact, it is this attitude of grown-ups that could be leading our next generation to become stereotyped conformists rather than original thinkers and innovators. And if we intend to drive home health messages and inculcate healthy habits we need to tailor our efforts to their cognitive potential.

That children indeed think and discover the world differently was first noticed by a Swiss scientist Jean Piaget in the early 20th century. He studied his own three children grow and was intrigued by how they behaved, played games and learnt at different ages.

With further observations and experiments, he propounded the theory of ‘cognitive development’, placed great importance on the education of children and is hailed even today, 30 years after his death, as a pioneer of the constructive theory of knowing.

He noticed that logic and abstract thinking had no place in the first 3 stages of a child’s development that spanned from infancy to age 11. Therefore trying to explain concepts such as“ healthy living increaseslife-expectancy….” to them would be wasteful and boring.

Small children, aged 2 and 7, like to discovering the world through their senses and by their rapidly developing motor skills. Colourful toys, tasty food and lots of action, supplemented by instructions from parents, teachers and peers make the perfect recipe for their learning. They cannot ‘imagine’ invisible germs on their dirty hands for example, unless depicted by an animated cartoon.

Younger kids will wash their hands before meals only because “mother told me to”. But as they grow to 10 they love participating in large active group exercises of hand-washing, more as a fun game, that can then be turned into a regular habit through regular reinforcement by superiors.

When dealing with older children, the techniques need to be different, as imagination and logic start making their appearance between ages 11 and 16. Posters, games and quizzes work best but debates, which require logic, still remain beyond the fringes of their grasp.

But once logic and abstract thinking get into their heads, students between 11 and 16 begin to engage passionately in debates and discussions! The best way to get these youngsters to learn (let us avoid the word ‘teach’) is to them a contentious topic for debate around the chosen subject. As they search and discover evidence, articulate their opinions with conviction, get rebutted and challenged by the logic of their opponents, they begin a new journey of exploring the world with their newly acquired cognitive skills.  They learn better this way than what textbooks or teachers can teach them.

Promoting healthy habits in children is therefore not an easy job of simply sermonizing “do’s and don’ts”. HOPE Initiative has emerged as a “Centre of Excellence” for exploring such innovative ways to reach out to students.

As published in HT City ( Hindustan Times) dated 29th December, 2013.

The Doctor’s Dress

The familiar white coat worn by physicians as their distinctive dress for over 100 years, has started generating murmurs of controversy.

It is not uncommon to find the blood pressure to be higher when measured by a white-coat-wearing-doctor in the hospital or clinic than the readings obtained at home by relatives.  This is due to the anxiety that the white coat and the hospital setting evokes in patients, and has been termed “White Coat Hypertension”. Mature clinicians often routinely subtract a few points from these measurements when entering records in case charts or calculating the dose of anti-hypertensive medications to be prescribed.

The white coat scares children too.  Kids often express their dislike for this dress by crying and screaming and by denying access to their bellies or chest for examination by paediatricians in this attire. Many pediatricians across the world have folded up their white coats and taken to informal colourful dressing to get closer to their little patients and win their cooperation.

Psychiatrists do not like the white coat either. It portrays them as cold insensitive “clinical” people, dissecting human feelings and forcibly dragging their emotionally disturbed patients to the horrific “shock chambers”. They are rebelling against this dress code to break their stereo-typed image.

The ‘white coat’ or the ‘lab coat’ is a knee-length overcoat worn by professionals in the medical field or those involved in laboratory work to protect their street clothes, symbolize professionalism and indicate a closeness to science. The modern white coat was introduced to medicine in Canada by Dr. George Armstrong (1855–1933) who was a surgeon at the Montreal General Hospital and President of the Canadian Medical Association. It was used in the late 19th century by physicians to represent themselves as scientists, from whom they borrowed the dress, in contrast to quacks, faith-healers and butcher-surgeons who wore black coats then.

In sharp contrast to what the mutinous splinters might say of the white coat, opinion of patients and the public is overwhelmingly in its favour. A recent study conducted in the United Kingdom found that the majority of patients preferred their doctors to wear their white coats. They reported feeling more reassured and confident  with doctors who were “professionally” attired than those dressed casually in jeans and T-shirts.

A white coat ceremony (WCC) is a relatively new ritual that marks one's entrance into medical school and, more recently, into a number of related health- professions. It originated in Columbia University’s College of Physicians and Surgeons in 1993 and involves a formal "robing" or "cloaking" in white lab coats.

Over the last century, the white coat has protected not just the clothes of doctors but their stature too, and given them their distinct identity and adulation.

Those who wear it must do so with suitable dignity and uphold what it represents.

As published in HT City ( Hindustan Times) dated 22nd December, 2013.

How Doctors Think

Doctors may not be the brainiest in society; yet the fascinating ways in which they think and make decisions has been the subject of interesting research. A book by Dr Jerome Groopman that deals with the subject has hit the best-seller list.

There are some parts of the brain that a doctor uses preferentially over others, memory being perhaps one of the most important to start with.  It begins from the time a youngster thinks of taking the entrance exam to medical school – he is required to read, retain and reproduce a large number of factual information and names of body parts and functions. Unlike the engineering, management, or law students, medical aspirants are hardly required to use mathematical problem solving, creative thinking, logic or thinking out of the box.  But ask them names and profiles of thousands of organs, tissues, cells and drugs, and they will have it on their fingertips!

In the next phase as they progress to clinical work, doctors learn to recognize “patterns” of symptoms and signs in patients, and try to fit these into the puzzle board of diagnosis.  Chest pain accompanied by sweating would suggest a heart attack, or jaundice with loss of appetite would fit the pattern of “hepatitis”, for instance.

When the doctor starts maturing as a clinician, he picks up through experience, a feature called “probabilistic” thinking. To take the example of chest pain for instance, he starts recognizing that the same symptom in a young 20-year-old woman is almost always of neuro-muscular origin, and hardly ever from the heart. On the other hand, if the patient is a 50-year-old overweight smoker with high BP, it is very likely to be a heart attack, and calls for immediate referral to a cardiac ICU.

With further development in his career, he starts factoring in several aspects of his patient in the process of decision making.  In other words, it is at this stage that he starts incorporating the “art” of decision making to the text-bookish science that he has crammed.  Does the vegetable vendor who has come down with cough and fever for 2 days after getting wet in the rain require to be subjected to a CT scan of the chest or would an antibiotic suffice?  Does the 16-year-old schoolgirl with recent onset vomiting require an endoscopic examination right away? What if her mother tells you that she had had these symptoms last year too when she was stressed before her final exams?

The mature doctor then is not just a repository of facts, information and knowledge. It is the unconscious assimilation of years of experience, spiced with a sensitive understanding of his patient’s concerns and constraints that make him take decisions that posterity seems to approve. 

A wine matured over decades may have the same content of alcohol as a recently fermented one, but the discerning taster can easily spot the difference.

Knowledge alone does not make a good doctor; the flavor also counts!

As published in HT City ( Hindustan Times) dated 9th December, 2012

Vitamin Overdose

Recurrent attacks of severe abdominal pain, renal stones, abnormal moods, and an attack of pancreatitis could well be due to an excess consumption of vitamin D. Dr Ambrish Mittal, a Delhi based endocrinologist, says he sees several patients with abnormally high blood calcium levels due to hyper-vitaminosis D, many of whom develop serious consequences such as swelling of the pancreas.

Dr Vjay Kher, chief of nephrology at Medanta Hospital agrees that there is a lurking epidemic of vitamin D overdose resulting in high levels of blood calcium, that choking kidneys and causing renal failure.

Vitamins are catalysts that in very small doses, regulate actions of several enzymes and make our body function smoothly. The discovery of this group of substances 100 years ago was indeed a major leap in medicine. Dr George Wald was awarded the Nobel Prize for discovering Vitamin A and proving its indispensable role in nurturing the rods in the retina that allow us to perceive light, and hence provide us vision.

Deficiency of vitamins soon came to be recognized, and the dramatic improvement of the patient’s condition almost as soon as the therapeutic dose entered the body started appearing as miracles.  Scurvy and delayed wound healing could now be treated with Vitamin C, Beriberi with Thiamine (VitamineB1), osteomalacia with vitamin D, night-blindness and dry cornea with Vitamin A and so on.

The question then that started being asked was “Why wait for deficiencies to occur before administering a therapeutic dose of the vitamin to cure it? If Vitamins are “good” things, then an extra dose should benefit more!”

That unfortunately is not always the case.  While consuming high doses of vitamins that are soluble in water (Vitamins B and C), and hence pass out through urine if taken in excess, are perhaps still somewhat safe, the fat soluble ones (Vitamins A, D, E, K) do not have an easy way out once they get into our bodies. And that is when the problem starts.

The condition of hyper-vitaminosis D has another angle. With the entry and popularity of bone scans  (dexa scans) and vitamin D estimation tests in India, our scientists, started reporting that as many as 90% of Indians were deficient.

What they thought they were raising was a national alarm in the population’s health interests however went a bit awry. They failed to define what was “normal” Indian standard, and shied away from asking that if almost everyone in the population showed a value that was less than that measured in the West, could the “normal” for us Indians be indeed different?

Vitamin D therefore came to be prescribed in higher and higher doses to make our Indian bone measurements meet up to that of the Westerners, and started echoing our national legacy of trying to catch up with our colonial masters. And while Westerners are now reducing their vitamin consumption, we are escalating our doses and gulping them at considerable risk to our health.

As published in HT City ( Hindustan Times) dated 14th October, 2012.

In Search of the “Middle Class Hospital”

When the middle class Indian falls seriously ill today, he is caught between the devil of an exorbitant 5-star private hospital that could drain all his resources, and the deep sea of the swarming government hospital where he needs to be fit enough to stand for hours in long queues to reach the doctor or the scanning machine, sometimes to be told then to come another day!

Let me start with the high-cost hospitals first. Have you ever wondered why they feature swimming pools, spas and shopping arcades selling Elizabeth Arden or Gussy? Do you think a “middle-class Indian” son who comes to see his mother suffering from terminal cancer, would   have a swim in the pool and shop for handbags after visiting hours?

The message runs deep. It is a subtle way to tell those with shallow pockets “ Stay away. This place is not for you”. That “middle-class Indians” rush in to these mansions where angels would fear to tread indicates either their naivety or a deep desperation to provide the best they can for their loved ones, at just about any cost or consequence!

The pitiable state of government and charitable hospitals is adding much of the misery of the “middle-class Indian” and promoting the prosperity of 5-star hospitals.  If you attend a meeting of directors and administrators of government hospitals, you will find the agenda to go something like this: 1. Construction (pushed by contractors); 2.Equipment (pushed by companies and agents); 3. Staff benefits and promotions (pushed by unions and lobbies); 4. VIP facilities (pushed by local politicos), and so on……but hardly one on Patient Convenience!

For instance, there are 2 ways of looking at a long queue of people standing impatiently in a hospital to get their registration done to see a doctor or to pay to get a test done. A private hospital will think of opening more booths and hire more staff to shorten the wait, while a government administrator will send a gun-wielding security guard to shout orders to make the frail patients make a straight line, and see the long line as a vindication of the hospitals demand!

The charitable hospitals have also fallen way behind in keeping up with patients’ expectations. Their age-old motto of serving the poor, is proving contrived. Patients are beginning to demand scientifically validated medical treatment and are no longer satisfied with charity alone. A patient suffering from coronary artery disease is now seeking angiography and bypass surgery, and is no longer gratified with doses of subsidized vitamins and words of faith, doled out by an inadequately trained specialist.

Hospitals, even if they are “charitable”, are not charity homes. They need to be assessed by their capability to provide good medical care in convenient, comprehensive and dependable manner, with well-trained doctors at the helm. And getting enough of the latter for small salaries is getting almost impossible for most of them.

Where then should the “middle-class Indian” go?

As published in HT City ( Hindustan Times) dated 7th October, 2012.

The Debt Trap of Medical Care

A major health problem, appearing suddenly out of the blue, can squeeze the family’s resources to the last drop and land you in a debt trap, as I learnt from Rahul’s case recently.

Twenty- year old healthy Rahul, who hails from a village near Agra, was perfectly well till the day before, playing cricket with his friends. That morning a gnawing pain started in the upper abdomen that increased in severity to a deep boring one and started radiating to his back. He threw up a few times, started sweating and became breathless. His father, Om Prakash, came back from the private sugar mill where he worked as a supervisor, and carried him in a borrowed 3 wheeler to the nearest local doctor.

Sensing something serious, the doctor referred him to a nearby hospital. Having diagnosed Acute Pancreatitis, a condition that could turn potentially fatal, they referred him to a specialized centre. His condition continued to worsen, and Om Prakash could not bear to his only son of 6 children, fight for breath. Unable to risk his son’s life he took a loan of Rs 1 lac from his colleagues, and brought him  to a major corporate hospital in Gurgaon that has the reputation of providing the best services.

Rahulcondition remained critical and had to be admitted in the Intensive Care Unit. After many uncertain moments and galloping expenses, his condition stabilized by the 3rd week doctors thought him fit for discharge.

Om Prakash had got back his son but had taken loans of Rs 15 lacs to meet his son’s hospital expenses. He had mortgaged his small house as well as the future of his 5 daughters.

The last 3 weeks had been so tumultuous that he had not had time to think about what the consequences could be.  With a monthly salary of Rs 4500/- how would he ever pay back the loan? What would happen to his daughters’ education. And marriage? What if Rahul had another attack? Or if something happened to him, the only earner?

 This is the drama that we see being played out to numerous families in India. Good medical care is what they all need, and emotions often dictate that one should go for the best for someone you love. But when problems come up suddenly, we find ourselves unprepared to face the financial consequences.

With government hospitals either ill equipped or overloaded to cope with the number of patients, and with the gap widening drastically between our financial means and the sky-rocketing costs of good private medical care, middle class Indians are having a tough time deciding what to do.

Medical insurance is perhaps the answer but has still not won the confidence of most Indians as only 15% have it.  And getting them to pay up what they had promised when selling the policy can be harrowing.

The common countryman can only pray that fate does not lead him into the medical debt trap that Om Prakash has fallen into.

As published in HT City ( Hindustan Times) dated 23rd September, 2012.

Piles

If you have piles, and ever get the feeling “Why did this have to occur to me?”, all you need to do is broach this topic in your next party and duck for shelter from the deluge of experience, anecdotes and advice that will follow.

I know that there are better things to talk about in a party than the swelling in your rear end. But parties are hardly ever uniformly exciting, and you could pop this unusual topic if your attempts with sports, politics, economy and weather have drawn blank pauses from a grumpy next-seater.

The first feeling you are bound to enjoy is the overwhelming reassurance that you are not alone.  Most would own up. In fact as the conversation and the circle get larger, you could give those who don’t have them or don’t know if they do, a bit of inferiority complex!

A survey showed that one of every 2 adults have piles and the frequency gets higher as we grow up; many go through their entire lives not knowing if they had it at all while most get to know only during a medical examination.

Piles, or hemorrhoids as they are called in medical jargon, are swollen veins in and around the anus. If they can be seen or felt outside, they are called external piles, while those located inside the outlet are called internal piles.

Painless bleeding is the main symptom of the internal variety. They come to attention when fresh blood, in streaks or drops, are seen on the pot while passing stools. This often causes panic in the morning especially when it was just last night that one munched spicy peanuts with drinks and felt on top of the world with friends. Typically, bleeding occurs when stools turn hard and you resort to straining to get them out.

Interestingly, the external ones, like barking dogs, don’t usually bleed or bite.  Thy can get scratchy, swell or turn painful, and draw your attention to your chronic constipation.

There is another good reason to bring up “piles” as a party topic. The number of treatment options that you will get to hear will make your head reel. You can spend a sleepless night tossing options such as laxatives, herbs, medicines, kayam-churan, band ligation, injection therapy, cryosurgery, hemorrhoidectomy, and many more.

Let me share something exciting that I learnt at a party when the conversation had indeed turned to piles at a boring juncture. Scientists have noted that they occur only in animals that stand and walk erect, such as man and ape, and may have something to do about blood gravitating down to the caudal end and not being able to flow freely up due to straining and constipation in that posture. None of the 4-legged ones seem to get them. 

The next time therefore you hear someone flaunt that he does not have piles, ask him how he moves at home! Hic!

As published in HT City ( Hindustan Times) dated 16th September, 2012.

Know about Dengue Fever

Dengue is having a free run this autumn, thanks to the abundant rains, ramapant water logging and unrestricted breeding of mosquitoes. Almost every household has either had a bout of fever in the last month or is likely to in the next one.

Recognizing Dengue Fever (DF): It is a viral infection transmitted by mosquitoes and presents as a sudden febrile illness of 2-7 days’ duration, with 2 or more of the following:

• Headache
• Pain behind the eye balls
• Severe body aches
• Pain in the joints
• Rash

One of the main concerns in Dengue is the fall in platelet counts from its normal range of above 150,000. Platelets play a vital role in preventing or stopping bleeding from small blood vessels. Infusion of platelets is required only if they drop to below 20,000 or when there is active bleeding. Remember transfusions have their own risk of transmitting other infections, of allergic reactions, and their effect lasts barely a few hours.

The other concern is shock. Dengue sometimes causes fall in blood pressure due to leakage of plasma from capillaries with loss of blood volume. The Hemoglobin level paradoxically rises and urination may become less. Some patients show liver involvement (Serum ALT/AST, Bilirubin) or kidney dysfunction (increase in serum creatinine). These usually settle down with good intake of fluids and calories.

Tests for Fever: It is important to remember that all fevers may not be due to Dengue and Enteric Fever (Typhoid), malaria, and common flu are equally ramapant these days. Further, while Dengue is a viral illness with no specific medicines, typhoid and malaria need specific medications and can be far more dangerous to life than Dengue.

If fever persists for more than 2 days and is severe, tests should include Hemoglobin, white blood cell and platelet estimations, a peripheral smear for malaria, and a serological test for Dengue. The serological test for typhoid often does not show up in the first few days of this infection and hence can be misleading if done too early.

When to worry: If you have contracted Dengue, lie in bed and take rest for atleast a week, drink lots of liquids (water, juices, soups, nimboo paani or ORS), take paracetamol tablets ( upto 3 a day), avoid aspirin and brufen as they may trigger bleeding,  apply balms on your head and listen to soothing music. Consult your family physician but do not panic. Remember that there is no specific medication for Dengue and yet recovery is the rule.

Critical phase: Contrary to popular belief, the danger phase in dengue is not the 1st 2-3 days of high fever, but around the 5th to 7th day, when the fever begins to settle. Many people who are in a hurry to get back to their normal lives often crash during this phase with low BP and shock. It is therefore crucial to relax at home for a couple of days more.

I hope employers and school principals do not sue me for this advice!

As published in HT City ( Hindustan Times) dated 8th September, 2012.

Medical Research in India

“The quantity and quality of medical research being undertaken in India is embarrassingly little”, said Dr MK Bhan, secretary, Department of Biotechnology, Government of India, while addressing a group of Indian gastroenterologists in a meeting in Delhi on 1st Aug.  He painfully pointed out how research was a low priority amongst most medical schools, and how very few doctors were taking up research as a career option.

Many might well wonder why research is important at all in medical science. Is it not well-established medical practice that a patient seeks from his doctor or hospital?

The National Institute of Health in USA has shown time and time again how research improves teaching, and teaching lifts the standards of care. It might be hard to accept at face value, but an example or two may make it clear.

The treatment of breast cancer, for instance has undergone major upheavals over the last few decades. It started more than a century ago with the concept that the tumor should be removed with as wide a margin of normal tissue as possible. Cancer surgeons therefore became more and more aggressive in performing extensive radical surgeries resulting in severe mutilations and death.

It required innovative thinking and a research mind to attempt less aggressive resections, but coupling it with other forms of therapy such as chemotherapy or radiotherapy. Over the last 2 decades, breast cancer survivals have therefore paradoxically improved several folds with less aggressive surgery. That is all thanks to medical research.

Prof BS Ramakrishna, head of the Department of Gastroenterology at Christian Medical College, Vellore, echoed the same sentiments and drove home the point with a simple example. While we all know, that the introduction of Oral Rehydration Solution (ORS) is a single piece of research that has helped pull back millions, especially children, from the jaws of death due to dehydration.

What scientists noticed however, was that although ORS prevented dehydration and death, it did not really reduce diarrhea! Medical research undertaken at Vellore showed that while much attention had been given to the small bowel in reabsorbing fluids and sodium, the decreased capacity of the large intestine in this condition had gone largely unnoticed.

Nursing back the large intestine with its special fodder, short chain fatty acids, therefore emerged as a better alternative, along with ORS, not only in tackling dehydration, but cutting diarrhea as well.

Established medical practiced has been compared to a pond of water. It may be clean to start with, but often gets stagnant and stale. Research is a flowing stream that does not let stagnation set in. It is essential therefore if present forms of medical care and treatment have to improve.

As published in HT City ( Hindustan Times) dated 2nd September, 2012

Liver Cancer

Liver cancer, that recently claimed the life of the ever-smiling senior Maharashtrian politician and ex-CM, has become a hotly researched and discussed topic in hepatology meetings in the last few years. The reason for resurgence in interest in this disease, acronymed HCC (Hepatocellular cancer) stems from the recognition that it is the 5th commonest cancer worldwide, claiming around a million lives annually, but equally from the new understanding of this unique cancer, methods of its detection and specific treatment modalities that are indeed curing many.

Cancer, as we all know and fear, has long been considered to be an universally and always fatal disease. Not any more! Doctors, who once talked of 1-year and 5- year survival rates are now beginning to talk of "cure". And HCC is joining this list after lymphomas, leukemias, colon and breast cancers.

For one, doctors have realized that HCC usually does not occur in "anyone"; it needs a hot bed of a diseased liver or a longstanding liver infection with Hepatitis B or C virus to occur. If patients with these predisposing conditions are checked up frequently, it stands to reason that cancers would be picked up very early and removed.

Dr Okuda, a Japanese hepatologist in the 80s, who periodically screened all his patients of liver cirrhosis with meticulous ultrasound examination, soon started finding small round tumours springing up in the liver. Once picked up early, they could be removed by surgery or burnt with chemicals, producing "cure" in a few.

Taking up on this cue, scientists went a step further in all directions. Better technology, such as triple-phase contrast enhanced CT scanning and MRI led to higher pick-up rates of even smaller tumors. Further, other methods of destroying tumor cells within the liver emerged such as burning it with a radio-frequency probe inserted into the tumor, selective deposition of anti-tumor drugs or radio-isotopes into the lesion through an arterial catheter, and selective drugs.

Not to be left behind, surgeons joined the fight by resecting affected portions of the liver or removing tumorous livers and transplanting healthy ones in their place.

Despite these advances, what then makes liver cancers turn fatal? The commonest cause is if the disease is advanced and has spread already to other parts of the body when detected. Mistaken diagnosis and failed initial therapy come much lower down.

Liver cancer has also taught us that it comes on almost always in diseased livers. The importance of checking and screening for Hepatitis B and C cannot therefore be over emphasized. If found positive, and and the infection timely treated, cancer risk recedes. While infections are on the decline in developed countries, exponentially increasing consumption of alcohol is likely to keep hepatologists in the business of treating HCC in the next few decades to come.

As published in HT City ( Hindustan Times) dated 26th August, 2012

Warning about drug side-effects often help create them

Funny as it might seem, patients who are warned too much of possible side-effects before being given a medication, seem to experience them more often. Describing this phenomenon as the NOCEBO effect, German researcher Winfried Hauser has recently shown that patients anticipating side-effects such as giddiness, headache, constipation or lack of concentration, experience them more often than those who take the drug without being told about them.

This new finding fits well with what physicians have suspected all along, that the body’s response to therapy often depends on the patient’s belief with which he takes it. Some of the benefits of medicine undoubtedly come from the positive anticipation that a particular drug will work as intended -- easing arthritis or relieving wheezing, for example – called the PLACEBO effect. On the flip side our belief in a drug’s side effects may actually cause us to suffer from them as well.

The role of suggestion and belief in obtaining a positive response from treatment is well known. Scientists have shown that PLACEBO medication, that is one which has no active ingredient but looks like a drug, such as an empty capsule, often produces remarkable benefit when taken with positive anticipation of relief.  As many as 50% of patients report benefit in headaches, abdominal pain, dyspepsia and sexual functions with dummy medicines consumed in good faith.

Dr Winfried, an expert in psychosomatic medicine, who has visited India two times, feels that imagination and fears of patients can have just the opposite effect. When cautioned that a drug may cause sexual dysfunction, for example, a larger number of patients taking it report experiencing it.

A lady who consulted me with the history of breaking into allergic hives on taking virtually every antibiotic had a similar reaction when administered a vitamin capsule that looked like an antibiotic. Her hives disappeared when she was told and assured that it was a vitamin and not an antibiotic.

Practitioners of alternative and indigenous systems of medicine bank more on faith and do not usually mention side-effects of their therapy. Patients too therefore consider these innocuous and harmless, and consequently do not report side effects with their use.

Is keeping patients in the dark about a drug’s potential side effects, then the only solution?  In modern times it would be clearly not ethical. What experts propose is “contextualized informed consent,” that takes into account the possible side effects, the patient being treated, and the disease involved. While it will be clearly important to caution against potentially dangerous side effects, such as drowsiness while prescribing anti-allergic drugs to a person who might drive a car for instance, mentioning lack of concentration with an anti-diarrheal to an exam-going student may cause unnecessary harm.

While modern medicine requires that all potential effects of therapy, beneficial as well as harmful, be placed on the table, which aspects to highlight and which ones to downplay remains a matter of the wise doctor’s discretion.

As published in HT City ( Hindustan Times) dated 19th August, 2012.

Cancer Takes the Final Bow

The ovation that has marked Yuvraj Singh’s recent return to the cricket field has much more to do with just a cricketer’s homecoming to the lime-lit pitch. It has come to symbolize human triumph over a disease that has till now been considered invariably fatal.

Yuvi’s rendezvoux with the rare germ-cell cancer, starting from its delayed diagnosis, his hesitation to confront it and start treatment, the bewildering experience of seeing his bald head in the mirror, his anguish of having to sit away while his team played on the field have made his cancer a touching human story for the public. And, in our all too familiar Bollywood style of “All’s well that ends well”, his return to the cricket field with hair on his head gives us the deja vu feeling at the climax when the villain is finally bashed up by the hero.

Our perception of cancer has been undergoing considerable change over the last few decades. Rajesh Khanna’s epic movie “Anand” depicted it as a “tragic” illness which ultimately took its toll. Fighting it was not much of an option, and going down gracefully is all that one could do.

Kylie Minogue’s affliction with breast cancer in the last decade rang a similar bell as that of Yuvi’s, and made women both aware and confident of dealing with a disease that has haunted them. This Australian pop singer celebrity’s untimely detection of breast cancer, her long fight with the disease, her candid disclosures of her illness, and her final victory over it heralded by her return to the stage helped convince many that this too was possible.

Five of South American leaders have been diagnosed with cancer. And as is the spirit of our modern times, they are all battling it well and continuing to lead their nations. Fidel Castro, the veteran Cuban leader, was the eldest and most senior one to undergo surgery for his disease. Hugo Chavez, the outspoken Venezuelen president has undergone several surgeries for his cancer and has been probably certified cured. Argentina’s elegant lady leader Christina Fernandez de Kirchner had thyroid cancer, from which she has recovered. Two of Brazil’s leaders, the current president Luiz Inacio Lula de Silva and the past Dilma Rouseff are cancer patients. And in neighboring Paraguay, Fernando Lugo is battling cancer too.

Cancer is no longer a disease that is rare and occurs only to others. It has found its way from remote corners to the backyards and now to our homes. What however has changed in recent times is our spirit – from an easily yielding one in Anand to that of an indomitable and resilient one, fuelled by our resolve to return to the field to play again.

As published in HT City ( Hindustan Times) dated 12th August, 2012.

What Money Cannot Buy

Affluence sometimes serves as a double edged sword, getting you and your loved one access to high quality medical care in 5-starred hospitals, but at times buying you heaps of misery and suffering as well.

Mr Gupta’s 40 year old son, who looks after the family’s thriving businessis unable to come to terms that his father cannot be saved despite any amount that he is ready to spend.

Mr VK Gupta (name changed), 87 had ben diagnosed with liver cirrhosis and has been ailing since then with weakness and swelling of his feet and abdomen. Last month he had slipped into liver coma and respiartory failure. The affluent business family, wanting the best treatment for their father, had air-lifted him to a very modern ICU in a posh tertiary care hospital in the capital for care.

My encounter with the family was during ICU rounds. While an excellent team of doctors took as good care of him at par with the best hospitals of the world, he continued to sink. They monitored his his blood counts, creatinine, electrolytes, albumin, ventilator pararmeters, urine output, pro-calcitonin levels, SOFA scores and so on but he reamined ventilator dependent and unresponsive. An equally excellent team of young nurses performed 290 nursing tasks every day for him – from cleaning his back and airways, checking his IV lines and catheters, ensuring the right kind and amount of tube feed went into his body, provided eye and mouth toilet and an endless list of things that kept him technically alive with his heart still beating although hooked on to machines and tubes. It had cost the family Rs 50,000 every day for a month, but they were prepared to go on as long as required.

During my daily ritual of counseling I learnt that they had spent around Rs 20 lac already.  What was frustration to the family however was that the money was not getting their father anywhere near cure. They were prepared to spend another Rs 50 lac for a liver transplant if only the doctors would try!

They found it difficult to accept that their father was too old to undergo a major surgery at 87, and that how, for the 1st time in this condition was too frail to even give it a try. For the 1st time in their lives, they were confronted with a situation where money in any amount seemed to prove inadequate to solve their problem.

Mr Gupta had started his business 50 years ago that had brought him and the family to prosperity. The thought that they could shying away from any expense his treatment required, filled them with guilt.

While the old man’s soul seemed locked for weeks in an old, frail, diseased body, perhaps aspiring for release, the family’s wealth ensured that his pain was indefinitely prolonged.

I thought of all the poor villagers around Mohanlalganj who came to government hospitals, had much less means but more clarity of thinking to accept the inevitable.

As published in HT City ( Hindustan Times) dated 5th August, 2012.

Local Heroes Show the Way

Mr Pradeep Kumar Srivastava, a common looking man, is no longer a common man. He has climbed roles from a devastated patient of Hepatitis B for 8 years to a hero who has cleared the infection and now to an activist guiding others to prevent and treat this deadly infection. And who can be more convincing than him to tell what it entails being a patient?

The ground under his feet had shaken 8 years ago when he, along with his friends, had gone for a screening blood examination in 2004 and tested positive for Hepatitis B. Although he worked in a laboratory as a technician, he did not remember any accidental exposure to blood or blood products. He had never had jaundice, and had felt perfectly fine till this test had robbed his bliss. In disbelief, he got the test repeated from 3 labs. All were unfortunately positive!

Advice kept pouring freely in. Some wondered how he was still alive, others said that there was no treatment and he was doomed to die, while many suggested going for alternative medicines. He was worried about his wife and small children and wondered how much time he had with them.

He however decided not to give in but to fight back. He took the long crowded road to SGPGI and after 5 hours of wait in the claustrophobic OPD hall, confronted me with the question “ Is it treatable?”

Further tests revealed that his infection was not a mild one; the Hepatitis B virus was actively multiplying in his liver, and the viral load in the blood was in millions. Considearble damage had already occured, and elevated levels of the liver enzymes SGOT and SGPT indicated that liver cells were still dying.

Having understood that the treatment had to be long, he started with oral anti-viral medications. The response was impressive; within 6 months, his liver functions had normalized and the viral load had come down significantly.

He attended our liver clinic with determined regularity. We watched his tests improve with each 6 monthly visit. His envelope antigen, a marker for viral multiplication, turned negative in 3 years, his liver functions improved to normal levels and he started getting the feeling that he may not die soon afterall.

He learnt much about Hepatitis B, attending all our seminars and film shows regularly. Convinced that he was indeed getting better, he joined the HOPE team in our yearly World Hepatitis Day functions on July 28 over the last few years, voluntarily lending his hands in the free screening camps, rallies and road shows.

God was probably watching. This year he greeted me with a grin when his HBsAg, the last marker of infection also turned negative. “Am I now cured for life?” he asked with baited breath. He was honored this year as a champion and a hero who had fought and overcome this infection with grit and perseverance.

As published in HT City ( Hindustan Times) dated 29th July, 2012.