perhaps a silver lining

I got my second vaccine dose yesterday. I’m done for now, but who knows how the final vaccination schedule will pan out, with newer strains, or variants of concern as they are called, still proliferating. These vaccinations could turn out to be an annual ritual. I’ve stopped questioning. What’s the point anyway?

A genuine accident, an act of carelessness, supreme recklessness, a deliberate plan, whatever it was, it has changed everything. I’m talking about the origin of the almighty Virus, of course. Our individual worlds are now tiny spaces in which the same activities repeat day after day, especially during the weeks of lockdown.

For some, it is getting the body battle-ready for COVID – drinking brews made from ginger, turmeric or pepper, squeezing lemon juice on everything that’s served, three different types of exercise regimens scheduled at intervals through the day . . .

For some, it is cleaning out the airways and lungs by inhaling steam with the hope of killing the viruses before they can get in there and start a cytokine storm . . .

For some, it is protecting body and soul through prayer, meditation and chanting, because they believe nobody in the world knows anything about this thing that has descended on us like a swarm of locusts . . .

For some, it is keeping track of the virus in real time, listening to Dr. Anthony Fauci’s pronouncements, picking through whatsapp forwards for new information, following the COVID stats gravely intoned by TV presenters . . .

For some, it is watching movies and shows on Netflix to escape into a world where nobody wears masks and there’s no social distancing, and life is the way it used to be . . .

For some, it is work-from-home, probably the least dysfunctional activity in these times. Those living in the tiny universe of their w-f-h jobs stole a march over COVID by sequestering themselves in makeshift home offices even before the lockdown was announced . . .

For some, it is filling up waking hours with up-skilling, to be eligible for job promotions ‘after COVID’ . . .

For some, it is cooking for family members w-f-h, doing dishes, sweeping, mopping, dusting, occasionally popping out at 7:00 a.m. to the neighbourhood general store for groceries and little necessities . . .

For some, it is reading all the unread books bought over the years, thankful for the uninterrupted time to read, at times marveling at the kind of books their younger versions had chosen to buy!

And so on . . .

*****************

Sometimes I feel like a bewildered child that has passed through Bowlby’s stages of Protest and Despair and has reached the stage of Detachment. My deadened limbic system doesn’t react to news anymore. My head does not process stats and graphs, or try to figure out details about the virus, vaccine technology or vaccine politics.

As far as I’m concerned, it no longer matters whether the Chinese painstakingly crafted the ‘novel’ corona virus in their lab at Wuhan, or tossed some bat viruses into the Hadron collider and zapped into existence a new species with superpowers.

I’m never going to know whether American and European scientists – as recent reports say – were involved in the gain-of-function research at the Wuhan lab or it was China’s independent project.

I will never know whether it is a biological weapon surreptitiously unleashed on the world, or an accident that serendipitously brought prosperity to China while decimating the economies of other countries.

The damage is done.

Nobody’s going to confront China anyway. Even Tedros and his WHO team weren’t given access to raw data on their fact-finding mission to Wuhan earlier this year. And if other countries were indeed involved they will go into a secret huddle, make deals, and issue a cleverly worded press statement. A thousand TV channels will convey it to a not-so-gullible, but ultimately powerless, public . . .

I don’t believe our vote is as powerful as it is made out to be, because most of the people who stand for elections are very similar when you scratch the surface and look.

I never said the world is fair to all, and it is very much in the natural order of things, for example, that CONMEBOL (governing body of football in S America) has got Brazil to agree to host Copa América despite being a COVID hotspot, because CONMEBOL has had much bigger losses than the ordinary citizens of Brazil, right?

The same goes for the International Olympic Committee’s reluctance to cancel the Japan Olympics this year even though 70% of the population does not want the Games held there. Risk-benefit analyses depend on who has more clout, not on what is fair or humane.

These corona years will pass into history in a couple of years. Millions will have died, millions will have been pushed into poverty and, yes, a few billionaires will have been created by COVID economics.

Alongside all this, though, armies of young Indians – all with their heart in the right place – will have quietly discovered how much they are capable of achieving if they use their smarts and their considerable skills for the greater good. The newspapers are full of stories of initiatives taken by Indians of all ages, most especially the younger lot, and they kindle hope that the future of our youth may not be as bleak as it seems.

This, then, is what I choose to see as the silver lining to this disastrous pandemic.

depending on dwarfs

Some Indians have been asking the government “Why did you send vaccines meant for our children abroad?”

It’s common knowledge that when Serum Institute of India (SII) agreed to produce the millions of vaccines the world needed last year there were certain licensing agreements with AstraZeneca, UK.

One of them was the WTO’s stipulation that 84% (not sure of this number) of the manufactured vaccine was to go to the COVAX Facility for distribution to low- and middle-income countries, ninety-two of them.

1.1 billion vaccines were apparently manufactured last year on these terms. So the vaccines sent abroad were not the ones “meant for our children”.

The picture is different this year. India has millions of cases and needs millions of vaccines. So India has had to renege on the deal to supply vaccines to COVAX countries. For a while, the country did gamely try to live up to being ‘pharmacy of the world’ . . .

The CEO of SII, Adar Poonawalla, is unable to scale up vaccine production because he does not have the raw materials. They are apparently sourced from 300 different suppliers across 30 different countries, and a typical vaccine manufacturing plant uses 9000 different materials (Indian Express, 30th April 2021)! The US and European restrictions on raw materials have hit production, yet he is under threat to somehow deliver!

Reminds me of the fairy tale ‘Rumpelstiltskin’. It’s like Mr. Poonawalla has been locked up in a palace in a room filled with bales of hay and asked – under threat of death – to spin the hay into gold like the miller’s daughter in the story! He’s waiting for the dwarf to come and work his magic, the dwarf being the US and Europe.

Everybody knows that we need international help to scale up vaccine production in the country: raw materials and patent waivers. The former has apparently been sorted out and the latter is in the process of being sorted out, if news media are to be believed.

As it is getting increasingly obvious that ‘no one is safe until everyone is safe’ it does make more sense for the world to pool its resources. However, by the time all the petty little quibbles are set aside and the bureaucratic machinery of each country is set in motion to let SII have the raw materials it needs, there could be more B.1.617 variants moving rapidly through the air, infecting more and more of the world.

World leaders have already talked about this possibility, so why are they dragging their feet on it?

news ticker in my head – scroll, reappear

One of my dearest friends is down with COVID. She is a neurologist who goes in to work at a general hospital everyday.

Right now she is being treated in the ICU of the same hospital. She has a bed, good medical and nursing care and as much oxygen and meds as she needs. These are the blessings we are counting, considering that her immune system was overwhelmed, two jabs notwithstanding.

I have no new thoughts. The same old thoughts have been going round and round in my head since March 2020. With more information – especially contradictions in scientific news regarding corona – getting funneled into my eyes and ears everyday, the nonsense in my head only gets more nuanced, my understanding doesn’t get more lucid!

The healthcare infrastructure in India has always been inadequate, so it’s absurd to think we could scale up at a time like this! When it comes to healthcare, we sometimes seem like a country without a standing army, one that depends on a hastily assembled militia to beat back attackers. In fact, the healthcare system not being overwhelmed in 2020 was the surprise, and what’s happening now is more on the lines of what we expect based on decades of observation.

Yes, the second wave was swift and ferocious, but not unexpected. We knew it was predicted to hit in April. I’m not surprised the world is asking why we didn’t prepare for it. Every year, when forest fires rage through California, I question why the American government doesn’t prevent them by managing their forests better, why it exposes its citizens to the danger of losing lives and homes. Likewise, the world is looking at India accusingly with astonishment and disbelief – you knew the danger, yet you did nothing!

The same thing happens every monsoon when rains lash peninsular India. No steps are ever taken between monsoons to avoid catastrophes like landslides, flooded cities and the inevitable loss of lives.

Qualified people like environmentalists and urban planners have advised successive governments for nearly seventy-five years, but very few of the measures have been implemented because of lobbying by entrenched interest groups that need development to not take place, or ‘development’ to take place in a way that might be detrimental to everybody else. So we have gradually descended into the state called learned helplessness that was first described by psychologists Seligman and Maier in the 1960s. At least, I know I have.

Right now, we have a shortage of oxygen. If what I read is true, why do Delhi hospitals rely on Assam, nearly 2000 km away, for their oxygen? Last October, the government announced that 150 new oxygen plants would be set up on the premises of various hospitals, but only 33 apparently were! And we also have a vaccine shortage now. Like a whole lot of others in Bangalore, my second shot is due but I’ll have to wait.

Balancing economic activity with COVID safety has proved impossible. People have been meeting and there have been large crowds on streets and in shops and markets. Only about 50% of people are masked, not always effectively. All these people are confused by the contradictory information they have been getting about the virus, COVID symptoms, vaccines, precautions, treatment, and even regarding the existence of the virus itself, for one whole year!

Between December 2020 and March 2021 my son and I have gone up into the hills surrounding Bangalore eight times on one-day treks and have often drifted into conversation with villagers. They insist there is no corona virus, nobody has fallen sick in their village, nobody has died, and they sympathise with us for having to live in unhealthy Bangalore!

Only large gatherings are reported in the media, the ones they call superspreaders, though the small ones are equally dangerous. It’s like saying the Great Pacific Garbage Patch is the only significant collection of plastic pollution, when we know that plastic pollution is everywhere, in every nook and corner of the world that’s overrun by human beings. There have been smaller gatherings over Ugadi, Easter and Ramadan, but the thing is, when things are this bad and confusing, people go rushing to their gods for help. Besides, people need to be around others to feel connected, to feel they are not alone.

Pandemics have happened before. They are random events. We have been the undisputed reigning species for so long that we can’t imagine another species getting the better of us, making us scoot for cover for a change. It’s not just a viral disease, it’s a lesson like plague epidemics of the past were lessons in hygiene that taught people filth, rats and the plague, go together (though the role of rats in the Black Death is now disputed!). The lessons might differ depending on where we live, though – the lesson for the Chinese could be different from the lesson meant for us or Australia or Brazil, if geopolitics underlies this scourge as some news reports claim.

The rapidly mutating virus is hard to vaccinate against perfectly, 70-90% immunity at best. It’s transmitted through the air we breathe. All we can do is mask up, not go close to others and not give it to ourselves by scratching our noses with contaminated, unsanitised hands. Even after receiving our two jabs. We need to protect ourselves – individually – because nobody else can. The government can only order lockdowns and try to ensure vaccines and medical facilities are available.

A pandemic comes in waves. It follows a pattern of its own. There could be more surges coming, in different countries at different times. Governments will be blamed for every surge, and extolled in the media every time a wave ebbs. In the larger scheme of things epidemics come and go and we don’t have as much control over the earth and its other inhabitants as we think we do. Scientists’ projections have some validity but, with all the new variants, there is no telling.

Stories of people dying of COVID are sad. They had no time to protect themselves.

Sadder still are reports of people not being able to reach help in time to prevent death. They tried and lost.

Saddest are stories of very sick patients left waiting for a bed for hours outside hospitals on gurneys, of profiteering by hospitals and pharmaceutical companies, by those who hire out ambulances and hearses, by those who manage crematoria and burial grounds. They were let down by people they trusted.

Beyond saddest are the disgusting stories of callousness and cruelty of bed blocking scams, and hoarding of medicines and oxygen to sell on the black market, if these are true. They were cheated by fellow human beings.

Beyond disgusting are stories that leave us numb with horror, like those of a fire in the ICU of some hospital that charred patients to death. They were . . . what? I don’t know.

And these stories never stop.

Somewhere in the cobwebby parts of our mind we are dimly aware of a few sources of hope. We dare not cling too hard to them in case they prove to be wisps of gossamer and evanesce.

That dedicated doctors are silently working in hospitals all over the country, some of them regularly appearing on TV to answer questions and clarify doubts, or writing informative articles and making videos for the general public.

That our overworked, hardworking, nurses are tending to patients with all their might despite their drastically lowered strength caused by the flight of Indian nurses en masse to the middle-east to take advantage of the 10X remuneration for merely administering vaccines.

That ordinary people, especially our youngsters, have created helplines for people to reach out to, and are working tirelessly to pick up the slack where government measures are inadequate.

That we are back in a lockdown and – since it helped last year – it might work again . . .

Though, right now, it feels like we are pushing against something we can’t budge . . .

Kootgal, Ramanagara, Feb 2021

we were caught napping

We were caught napping. And now the Indian Medical Association is scrambling to reverse the notification that ayurvedic doctors are authorised to perform 58 types of surgeries listed by the government.

Here are some reactions:

 “The government’s decision to bring in a rule that allows practitioners in specified streams of Ayurveda to be trained to perform surgical procedures trivialises the medical profession,” Reuters quoted Rajan Sharma, the head of IMA, as saying.

(We mean it makes our entrance exams, MBBS degree, MS degree, our career goals, all totally irrelevant!)

“Let every system grow on its own strength and purity,” the doctors’ body said in a statement earlier.

(We mean, let us retain our purity because our system is evidence-based, let other systems follow their teachings, we will not judge)

In a statement last month, the IMA said, “The purity and identity of Ayurveda stand equally challenged. That the council prescribed modern medicine textbooks and Ayurveda institutions practised surgery with the assistance of modern medical doctors cannot be reason enough to legitimise encroachment into the jurisdiction and competencies of modern medicine.”

(We mean that it ceases to be Ayurveda once their students use textbooks meant for MBBS students, therefore have them write entrance exams meant for our students and get admission to our colleges on merit rather than sneak in like infiltrators across the LOC)

Reacting to the strike, IMA national president Dr R Sharma said: “Modern medicine is controlled and research-oriented, we are proud of the heritage and richness of Ayurveda but the two shouldn’t be mixed”.

(We mean we are proud of our heritage in general, we are fine with ayurveda aficionados going to vaidyas for treatment, but we would rather they didn’t pass off allopathic procedures as ayurvedic)

The Resident Doctors’ Association of AIIMS-Delhi, in a statement, said, “This step will not only encourage already rampant quackery, but also undermine the safety of the public. We request the government of India to retract this notification immediately”.

(We mean we consider other systems of medicine unscientific by the current scientific standards of the world, and we don’t want any sort of cross practice with them)

“It is obvious that Ayush is dependent on modern medicine, doctors, anaesthesia, antibiotics and equipment to perform modern surgical procedures. It fails the test of logic, this irresponsible initiative, placing thousands of gullible patients at risk”, the doctors’ body said in a statement.

(We mean we always knew that Ayush vaidyas were illegally using our methods and materials but we turned a blind eye because, until now, we were too indifferent to be bothered about the ‘gullible patients at risk’)

The Ayush ministry issued a clarification claiming that the technical terms and modern developments are a common heritage of mankind. The IMA rejected their clarification as being ‘deceptive camouflage of mixing the systems of medicine’.

(We know that nobody in India is concerned about intellectual property, plagiarism, ethics, fairness and things like that, so we don’t buy the ‘common heritage of mankind’ argument)

Dr R V Asokan, secretary general, said, “At any point of time, there are about 1.5 lakh unemployed young MBBS graduates. They do not have a place in the system. And these unemployed doctors can be captured for gainful employment wherever the government wants”.

(Do we mean we have been remiss in supporting our youngsters, employing Ayush vaidyas in their place, claiming we have no place for them in our system?!)

According to an article in The Times of India dt 15th Nov 2020, many hospitals, including large corporate ones and mostly in big cities, are employing Ayush doctors as RMOs, Emergency Casualty Officers and even to manage ICUs at night. Ayush doctors can be hired for as little as Rs 20,000 per month while MBBS doctors might have to be paid Rs 40,000.

(That means we took a short cut for monetary gains and the chickens have come home to roost, because the whole country now knows that vaidyas are being substituted for MBBS doctors!)

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This notification is unprecedented, but not surprising. It’s part of the general quest for reliance on all things indigenous, and seems part of a universal zeitgeist. Fortunately, patients use all systems – allopathy, ayurveda and homeopathy – and know which works for them for what ailment.

Nothing ought to change for allopathic surgeons because most surgeries need expertise that one acquires with years of experience, which our surgeons have.

ENT and ophthalmic surgeries are particularly complex because of the sensitive and extremely small structures packed into tiny spaces. One wrong snip could leave a patient with a huge deficit for the rest of his life. This is significant because ENT and ophthalmic surgeries are on the government’s list of permitted surgeries for ayurvedic doctors.

As a surgeon pointed out at a meeting recently, the challenge lies not in performing a routine surgery as much as it does in dealing with unexpected complications you find after opening up a patient, or unexpected events in the course of surgery. For this you need a large amount of experience that is only possible to garner through MBBS and MS courses because of the sheer volume of work.

Laws are one thing, reality something else. In this case, something wrong that was happening has been legitimised instead of being corrected. This is exactly the way our government regularises illegally-constructed buildings through akrama-sakrama, safety and fairness be damned.

While it is necessary to highlight this for the government, we also need to look inward and see where we are going wrong in the way we practice Medicine. We might need to revisit the Hippocratic oath to get our bearings again.

a surgical strike, literally

The Indian Medical Association has opposed the government’s move authorising post-graduate ayurvedic doctors to perform *58 types of surgical procedures. The government notification says they must be “practically trained to be acquainted with, as well as to independently perform” surgical procedures.

Ayurvedic doctors say, “Ayurvedic medical students are well-trained and have been performing surgeries since decades.” Well, we didn’t know.

In India, ayurveda is an accepted system of Medicine and comes under AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy). Even now there are people who prefer Puttur bone-setters to orthopaedic surgeons, and there are people who prefer ghee treatment for unclogging coronary arteries to angioplasty. It has always been this way.

From the viewpoint of allopathic surgeons, this authorisation has breached an invisible boundary wall that set apart and gave the right to operate only to experts with an MS in Surgery and a number of years of experience. With this notification, these criteria no longer have to be met! For surgeons, there’s a sense of devaluation of something hard-won, of evidence-based science being tainted with the unproven empirical, of dilution of scientific principles that are the cornerstone of modern Medicine . . .

What was the use of all those teenage years spent preparing for entrance exams, then four gruelling years of medical college, three more years of post-graduation in General Surgery and some more years in super-specialisation? What about all the sleepless duty nights over years and years, when all other things that go to make a life were shoved onto the back burner? The workdays spent scrubbing up and standing hunched over OT tables, with aching neck and knees? The list of *58 procedures doesn’t cover much, but it might well be a foot in the door, which is how the IMA is treating it.

The question is, will this list be adhered to and not treated as carte blanche to perform any surgery? People always find loopholes. It won’t be hard to, since allopathic-trained anaesthesiologists and gynaecologists are reportedly already working with ayurvedic surgeons in ayurvedic hospitals.

When the AYUSH ministry was formed in November 2014 it was obvious that it was an attempt to integrate all of alternative Medicine. We were given to understand that we were outside its ambit. Its objectives did not mention Surgery, hence this announcement came as a surprise to us last month. We didn’t even know there was an Indian system of surgery after Sushruta’s time, i.e. 6th century BCE!

A few years ago, a cardiologist friend of mine briefly worked at a small hospital owned by an allopathic doctor. The young duty doctor was unable to interpret a patient’s ECG when it was crucial, and my friend was shocked to know that both he and the duty doctor who worked the night shift were ayurvedic doctors. He resigned post-haste – handed in his notice – not waiting to find out what ayurvedic doctors would do with a patient in atrial fibrillation. Is the IMA aware that ayurvedic doctors are employed in hospitals owned and run by their fraternity?

Can allopathy and AYUSH be integrated? Is there enough overlap between them? The fact that anesthesiologists and other allopaths have been working with ayurvedic surgeons for years shows that some allopaths think so! This is the chink in the IMA’s armour, and the government is bound to wedge its new notification into that fortuitous gap!

So, now that the government has legitimised Fusion Medicine – not unlike Fusion Food or Fusion Music – it’s unlikely that ayurvedic doctors will only operate on their patients in ayurvedic hospitals using procedures based on ayurvedic principles. Now that the edifice of modern surgery has been dealt a body blow, I wonder what new system will evolve, and how it will affect different interest groups.

During internship, after graduating from college, I was posted to the Plastic Surgery Unit for a fortnight. A teenager with a 4-inch-long slash right across his face was brought to Emergency and I stitched it up. When he returned for suture removal the senior plastic surgeon was surprised at the neat scar and laughed when I said I was handy with a needle and thread much before I became a doctor.

So I was just thinking, some day tailors might be employed and authorized to suture small cuts and lacerations in hospital ERs! Why have boundaries? Let’s abolish them all!

* According to the notification, the procedures listed include removal of metallic and non-metallic foreign bodies from non-vital organs, excision of simple cyst or benign tumours (lipoma, fibroma, schwanoma etc) of non-vital organs, amputation of gangrene, traumatic wound management, foreign body removal from stomach, squint surgery, cataract surgery and functional endoscopic sinus surgery

(Taken from The Print, dt 12th December 2020)

no dilemma

I watched the documentary film, The Social Dilemma, yesterday. People working in the Attention Economy finally admitted they’ve turned the world into a Truman Show and us, social media users, into zombies to be manipulated. Something we’ve known for sometime now.

I think it might be too late for Millennials and Gen Z. The developing minds and personalities of this lot are irrevocably altered. Their phones are an extension of their hands and they feel a phantom limb sensation if physical contact with the phone is lost.

Of course, the social media czars didn’t know this would happen. They were so delighted with the pros that they didn’t even think there could be cons!

They started off well enough twenty years ago and users saw them as a blessing. And they are, no denying that. Currently, aren’t we all relying on social media to keep in touch with family and friends in the middle of this pandemic? It’s wonderful that we are able to take pictures and share them in real time with close family members who live in other places, see them on video calls, and have group chats.

It’s great that people in the industry are now talking about the downside of social media addiction, its negative effects on the lives of people, especially the young. But the hours, days, weeks and months frittered away online cannot be retrieved, and kids might have lost sight of whatever they intended to achieve when they graduated from school. Many of them might feel regret, anguish or a sort of despair like John Milton did:

How soon hath Time, the subtle thief of youth,
Stol’n on his wing my three and twentieth year!
My hasting days fly on with full career,
But my late spring no bud or blossom shew’th.

I haven’t seen rehab working too well for alcoholics and drug addicts and I don’t think it’s very effective for social media addicts either. So I guess we are looking at damage control starting with Gen Alpha, as kids born after 2010 are apparently called. Maybe Gen Z is indeed another Lost Generation, like the Lost Generation of the Great Depression of 1929, as some say.

Frankly, I don’t believe the industry that uses our data to manipulate us is capable of reining itself in despite the earnest efforts of the people who made this honest documentary. Getting on the prestigious Forbes List is too big a deal, and generating revenue through advertisements targeted at vulnerable users is a brilliant strategy for plutocrats. Can they give up their modus operandi now, when they only have a few more years before they reach the dust-to-dust point in their lives?

Economy was traditionally about industry, production, trade and consumption in a market system. The link between economy and survival of the human race as a whole was visible to everyone. There was some sense of ‘we’. Not to say it was a perfect system. It just seemed less oligarchic because getting into college, buying a house, buying a vehicle, etc. seemed possible if we saved wisely for them, unlike now, when we need bank loans for everything.

But the goals of the Attention Economy are not inclusive. It’s like a disguised form of feudalism, where land is substituted by data, and individuals give up their privacy/ownership of data in exchange for ‘free’ use of social media.

The business model of ad-based revenue deliberately creates echo chambers because more ‘clicks’ mean more eyeballs are drawn to ads. In the process, users receive and unknowingly spread fake news, hate and anger. There’s no telling what will happen if two echo chambers fed opposing ideas clash. Maybe riots of the sort we see nowadays?

It’s not too hard to imagine that the powerful plutocrats of the Attention Economy could bring about an apocalypse by sowing discord among people via our wonderfully user-friendly, unregulated, social media, while they stay safely ensconced in their well-stocked fallout shelters. Perhaps this is a conspiracy theory, but the Eugenics movement is apparently still alive, concealed behind public chatter about human rights!

Seriously though, perhaps it is time for an apocalypse, time for us all to leave, and let the earth recover. The earth has withstood ice ages, meteorite collisions, our own Chernobyl, Fukushima, the British Petroleum oil spill, and god knows what else, for four billion years. The earth will not be destroyed even if all life on it ceases. It’s we who are expected to survive within a narrow range of parameters called homeostasis! And every time we weaken a section of humanity out of greed we weaken ourselves as a species.

Though natural processes are not under our control and can cause life on earth to end anytime, one thing we can do is use social media to change the way this story is going, to the extent it’s under our control.

In general, the elements of a story’s plot are:

  • Introduction to characters and the conflict
  • Rising action
  • Climax
  • Falling action
  • Resolution

In this story we are the characters. The things we do to fulfil our aspirations as a species is the conflict. I think we are now in the stage of falling action, though optimistic people might say we are still in the stage of rising action. Resolution of our conflict depends entirely on how we want to write this story – because we are the authors. Will our story end with a catastrophe or a happily-ever-after?

broken systems

There are only two places in the world where live smallpox virus is stored today: in Atlanta in the US, and Novosibirsk in Russia. Their release or accidental escape could start an epidemic worse than this one. People of my generation have been vaccinated against smallpox, but our children and grandchildren haven’t, as smallpox was declared eradicated in 1980.

As with COVID-19, there is no cure for smallpox. Since we have proved incompetent at ascertaining the source of the corona virus and stopping its spread, I wonder about our ability to keep the smallpox virus from escaping and unleashing a worse pandemic than COVID. Scary thought, actually.

There is a UN, there is a WHO, and the world has agreed to store the virus in Russia and the US. Because, at one level, ‘All People’ are part of one ecosystem, and the UN decides where the smallpox virus should be kept. We normally trust that we are safe.

At first glance, the world looks like a well-functioning system. We pride ourselves on the globalization we have achieved. But there are actually thousands of separate subsystems that can unravel, disintegrate or collapse, and jam the system that makes uninterrupted movement of goods, people and ideas across countries possible.

A system cannot sustain itself if it isn’t smooth and dependable right up to the end. Like the absence of last-mile connectivity in the transport system of Bangalore that leaves you stranded when you get off a bus or the Metro. There’s nothing to reach you home safely from any station!

Or, take the IITs. The IITs were established to produce engineers to help India grow. But a large number of IIT graduates emigrate and become assets of those countries. But, for India, it’s a loss. A broken system.

ATM. It was supposed to make drawing money from the bank easy. Now there are people who skim your PIN number and steal your money, derailing the system that was set up for All People to use.

The current India-China border dispute has definitely affected a subsystem of the All People ecosystem of interdependence among countries. For example, our pharmaceutical industry relies on raw materials from China, so our export of pharma products to Europe is hit, affecting patients in Europe. And the unsold stock is probably not of much use right now to China either.

Despite safety mechanisms like ‘talks’ between foreign ministers and army brass, Presidents and Prime Ministers are ultimately human and prone to making costly mistakes. Some of them give themselves absolute power and follow no protocol. They can’t be reined in if they fly into a rage and trigger a war.

As an ordinary Earth citizen I can only spill my anxiety onto this page, and hope a war doesn’t erupt in this system that I have no control over.

Though I’m sure the Air Force knows what it’s doing, rather than celebrate the new Rafale fighter jets, I shudder to think we might need to use them.

********************

The systems that have evolved over the past few decades are not solid. There’s something hollow and self-serving about them, like they are designed to auto-shred like Banksy’s $1.4million painting.

Global village doesn’t mean Homo sapiens is now a close-knit species where members share cuisine, music and weed, and live like one giant hippie colony.

Globalisation is only about trade and commerce, even when it involves immigration and mixing of people from different countries. It’s a convenient word for benefitting from the foreigners one does business with, and pretending the benefit is mutual, thanks to the difference in base and quote currency values. And, of course, for pretending sweatshops don’t exist.

An immigrant is a visitor who requests a change to permanent resident status in your house. You warm to the idea of letting him stay because he has proved useful to you, conveniently ignoring the fact that chain migration will follow!

When mass immigration happens at a national level, governments can’t carve out new countries on the lines of Liberia to banish them to, not any more! I guess they have to wait for the tide of immigrants to mellow into the kind of much-celebrated ‘diversity’ we now have, the khichri made from whatever was tossed into the pot.

Immigrants can’t always go back to where they came from. I’m seventh generation or so in Karnataka and I can’t imagine being told to go back to Goa!

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Did we conquer SARS, MERS, Ebola, Zika, Nipah, H1N1 flu, dengue and chikungunya over the last two decades? Not really. Most of them went away on their own. And they can come back.

I have lived through days of worry when our daughter had dengue fever three years ago. She needed both of us for support as she couldn’t walk to the car, or into the lab, on her own, it was that debilitating. We would wait anxiously every day for platelet count reports from the lab and feel relieved that it hadn’t fallen further, or had gone up a bit.

Caripill was a fairly new medicine and was considered ‘possibly helpful’ in increasing platelets, no guarantees. There really was no specific treatment, only controlling fever, plenty of fluids and the usual general measures. It was a harrowing time.

How much harder it must be for families of COVID-19 patients. From not finding hospital beds, to being attacked by fearful neighbours, to having loved ones die of COVID, to facing difficulties in giving them decent funerals . . . One more broken system, healthcare. And everything to do with diagnosis and treatment is so very expensive, apart from being totally uncertain . . .

COVID is forcing us to pay attention to the design of this planet. We’ve ignored melting glaciers, rising sea levels, burning forests, plastic pollution and all the other hints we received. Now a tiny virus has sent us scurrying to the safety of our homes, too scared to even come out for foraging, let alone partying! And finding a vaccine is proving hard.

This is what we do know: Rapid urbanisation, destruction of forests and consequent loss of animal habitats that push wild animals closer to human habitations, and crowded animal markets, are the main reasons for transmission of animal viruses from animals to us.

This should be the first point of intervention, not a scramble for a vaccine when a pandemic is underway, though that has its place too, like now.

When I was a medical student corona virus, flavivirus (dengue, zika), paramyxovirus (nipah), filovirus (ebola) made up a laundry list of rare microbes at the end of the chapter on viral diseases. I never saw a single case.

When this is over – someday it will be – we might be wiser. Then again, maybe not, because human brains are adept at suppressing memories of hard times. ‘Out of sight, out of mind’ is how we seem to have dealt with zoonotic diseases so far. Or, to be optimistic, perhaps there is ongoing research that I don’t know about.

insurance exclusions

I was surprised when the Supreme Court recently questioned why insurance companies didn’t cover the cost of psychiatric treatment under medical insurance. Didn’t they? I didn’t know that. After the Mental Healthcare Act was enacted in 2017 the IRDAI (Insurance Regulatory and Development Authority of India) had issued a directive to all insurance companies to do so. But it obviously didn’t happen.

Okay. ‘Mental illness’ is a slippery slope for sure, like euthanasia, living will, Do Not Resuscitate orders, pro-life arguments and punishment of juveniles for heinous crimes. People have different notions of mental illness to begin with.

The Mental Healthcare Act, 2017 defines mental illness as follows:

A substantial disorder of thinking, mood, perception, orientation or memory that grossly impairs judgment, behaviour, capacity to recognise reality or ability to meet the ordinary demands of life, mental conditions associated with the abuse of alcohol and drugs.”

All of these are observations that a psychiatrist makes in the course of a patient’s Mental State Examination. His inferences can be construed as subjective and biased by anyone who chooses to do so. For example, if I think a patient is severely depressed and admit him because I think there is a risk of suicide, will the insurance company reimburse him if the suicide doesn’t happen? Will I be suspected of profiteering in some way from the patient’s hospital admission?

Insurance contracts are structured between providers and insurers both of whom benefit from a patient being hospitalised and sent through lab and radiological investigations, procedures or surgery. So ­– between doctors, hospital owners, insurance people and patients – does anyone trust anyone else anymore?

Regarding mental illness, insurance companies list exclusions in their brochures and policy documents, like depression, alcohol-related illnesses, ‘nervous breakdown’ and anxiety, all of which we recognise as symptoms of mental illness needing treatment.

Some are also smug about the fact that since most mental illnesses need only outpatient treatment very few patients can take advantage of the IRDAI directive to cover psychiatric treatment. True. Which means, any directive will look good on paper but won’t benefit patients.

There seems to be no consensus among concerned parties on what constitutes mental illness in spite of the legal definition. Our criteria are often unacceptable to non-psychiatrists, and the way insurance policy documents are worded suggests that insurance agencies think we are out to con them!

If we tell them that Panic Disorder is a mental illness and not a character flaw, that it is not something that afflicts a weak person who can’t face life, they are sure to think it’s a scam.

They are equally likely to think Major Depressive Disorder is sadness caused by ‘overthinking’ about things that don’t concern you, when your job is to work, eat, deal with your social media, watch something on your phone and go to sleep.

What about OCD? They most likely believe that a stubborn person who believes she knows best about cleanliness and perfection doesn’t deserve insurance if she ends up in hospital due to her cleaning mania. She’s clearly got her comeuppance.

People with AIDS, alcohol-induced health problems and reconstructive surgery are not covered by insurance. Looks like insurance people think these people brought it upon themselves and must be punished!

What about grief that eventually turns out to be a patient’s first Major Depressive Episode, precipitated by bereavement and needing hospitalisation?

And anorexia, bulimia and other eating disorders? I haven’t found any insurance company that covers Eating Disorders – they probably view rejecting food as entitled behaviour!

Autoimmune disorders are exclusions too! So are behavioural, neurodevelopmental and neurodegenerative disorders! How come? If anyone needs help, these people need it most because their illnesses are not curable and need lifelong treatment. The word insurance literally means assurance and comes from the French seur, meaning safe, which comes from the Latin securus meaning ‘free from care, secure’. The idea of insurance implies kindness and support – how ironic!

Don’t people who run insurance companies learn these things as part of their training? I’m sure they do, or else how would they be so good at finding loopholes!

There are only two conditions lay people seem to understand as mental illness: one, schizophrenia, only if the patient has florid hallucinations and delusions and is violent; two, the manic phase of Bipolar Disorder where even a casual observer can see that the patient’s behaviour is off-kilter.

No insurance agent seems to know that for every mental illness we see as strange behaviour, there’s something happening in the brain to cause it, just as the illnesses that his company does cover have an underlying malfunction in some organ. The disorder is not in the mind but in the brain, a large organ, just like the heart, liver, kidneys and lungs! As I’ve said before, Psychiatry is Neurology at a cellular/biochemical level.

I can’t imagine being a consultant to IRDAI and giving them advice on providing insurance cover for mental illness. It would be incredibly hard to convince people in the insurance business that a mental illness is as real as fractured bones or a ruptured appendix.

Half the world can’t imagine something they can’t see. They need something tangible like a BP reading or a blood test or a CT scan report, just as the other half of the world wouldn’t know how to hustle and make serious money instead of sticking with a safe job and a fixed salary. It’s just the way different people are wired.

No matter how much we try to increase awareness, the concept of mental illness is hard to convey because there are too many grey areas. For example, is someone with Antisocial Personality Disorder mentally ill? Or is he a morally bankrupt criminal who ought to be in jail? If admitted for surgery following an attack by a rival gang, and APD is diagnosed through his history, and psychiatric treatment is attempted, should the insurance company cover his psychiatric treatment as well? Who decides this?

The Indian Psychiatric Society has much to clarify about mental illness if we are to make things easier for our patients. To whom, I don’t know. The government? The IRDAI? Insurance companies? Why will the latter be interested when they don’t stand to gain?

I guess it’s down to lawyers, insurance people and the government – mainly the government – to come up with guidelines, preferably with input from the Indian Psychiatric Society. The sheer number of suicides in our country should make recognition and treatment of mental disorders a priority without creating so many stumbling blocks in the form of insurance exclusions.

hoping for miracles

Work has always been about food and safety since the beginning of human time. It still is for most people. But some of us have moved away from that basic premise and work to fulfill either our higher needs or unmet psychological needs. We tend to treat food and a safe home like collateral benefits.

At one extreme, Elon Musk says, “Why do you want to live? What is the point? What do you love about the future? If the future does not include being out there among the stars and being a multi-planet species, I find that incredibly depressing.”

I don’t deny that the launch of his manned rocket is a huge feat. It’s just unsettling to have news of his rockets and driverless cars juxtaposed with images of hunger and homelessness of millions caused by corona, then Amphan, Nisarga, Christobal and earthquakes and forest fires.

But then, everything else can’t stop just like that, right? So other things happening – like the launch of Falcon 9 with two brave people inside – alongside the march of the corona virus, worldwide protests against racial discrimination, and extreme weather events is just how life works.

Far removed from Elon Musk’s reality there is a lot of anxiety in the world of ordinary people right now. Anxiety, unfortunately, is not something that happens in a small corner of the mind. It involves the whole person. It can eventually cause high blood pressure, a heart attack or a stroke if it becomes chronic.

I think everybody knows most of this, but I’ll do a quick recap:

  • It starts with the eyes and ears observing and transmitting data to the back of the brain.
  • In a flash the information reaches the forebrain, which interprets it and sends it to the midbrain, the emotional part we have in common with lower animals, and we feel fear.
  • This sets off a cascade of stress-related hormones that course through the blood stream and whip the heart, lungs, guts and kidneys into action, preparing us for fight, flight or freeze.
  • So the heart beats furiously, blood pressure goes up, lungs pant out heaving breaths, sweat glands pour out sweat, the stomach churns, and there might be an urge to run to the bathroom, as all systems are in overdrive.
  • Within the brain itself, the hippocampus opens the folder of memories related to the current fear and reminds us how terrible it was the last time around.
  • And the amygdala computes the emotional value of the information and decides how awful we should feel.

Different neurotransmitters are released in the brain at each stage of information transfer. There are more brain chemicals swirling around in an anxious brain than the number of mind-altering ingredients in a glass of LIIT!

Anti-anxiety medicines stop this hectic activity and reduce restlessness, depression and confusion. I prescribe them if anxiety is severe, and only for a short time, because they cause dependence in the long term. So they are not a solution.

The mind of a super-anxious person is like a blast furnace. Somebody has to collect the slag, turn it into skid-resistant asphalt aggregate and use it to pave the rutted road of his life, and that’s what I do. I use the period of relative calm when a patient is on meds to sort out things through therapy – to some extent. So this is only a partial solution and that too, only for some patients.

I realize that one might learn all the mental gymnastics therapy can teach, but when there’s hunger and fear and creditors knocking on the door, autosuggestions to be positive might seem delusional. There is a limit to cognitive restructuring and trying to neutralize negative thoughts in the face of reality. And reality is so harsh for millions that therapy doesn’t even enter the picture; it would be like Marie Antoinette allegedly said, “let them eat cake”.

There isn’t always a simple solution, hence the number of corona-related suicides in the news. We need more than psychiatrists and mental health workers to reduce the suicide rate because people don’t kill themselves for the simple 2+2=4 reasons that relatives and friends usually give the police. Despair – a complete loss of hope of getting support – pushes people over the edge when a trigger like corona comes along and wrecks their fragile financial systems.

I hear from those who received regular rations from the Public Distribution System in the last four months that they were okay because they didn’t have to go hungry during the lockdown. That, and physical shelter, is what we didn’t give the migrant labourers who wound up walking across the country for thousands of miles to reach home.

As I said in my last post, we can’t control everything in life. The idea of God is a natural outcome of people having to deal with a difficult present and an unseen future, like now. Hoping for miracles is not that different from a therapist telling you to be positive in a hopeless situation.

I sometimes think that what people are going through is more like grief at the death of someone dearly loved than any other emotion. The new normal is an unalterable reality and we are never going to get back the life we knew and liked. There’s a profound sense of loss.

Those who depended on the gig economy in some way, including the migrant laborers who trekked across the country in thousands, are devastated. Even those who stayed afloat financially feel grief for the loss of a familiar way of life, mixed with relief and gratitude as in ‘there, but for the grace of God, go I.’

People who had slowly crawled out of poverty are mourning for the lives they had painstakingly constructed, rupee by rupee.

  • I talked with Kiran, a 23-year-old who works for a small event-management company putting up decorations at venues. No events, no gigs, no income.
  • Ashwini, a young assistant at a dentist’s office, has been on half-pay since her employer sees only occasional emergency cases due to corona risk.
  • Sunil, the barber near the market, shut shop just before lockdown and rushed back to his hometown. The owner of the general store next to the barbershop says he isn’t coming back now fearing institutional quarantine.

I don’t know how these people will rebuild their lives when this sad chapter is over. Maybe they are more resilient and stronger in spirit than I think. Mothers forget the intense labour pains of their first delivery and go on to have more children – my friend Mario’s mother had fourteen!

Viktor Frankl, the famous neurologist and psychiatrist, did a lot of meaningful work after surviving the Holocaust. He lived to be 92. Maybe the ability to forget pain – despite having every single memory stored somewhere in the brain – is a gift. It’s probably what keeps us going, because none of us go through life unscathed.

changing constructs

There’s much talk among psychiatrists about dealing with people affected by the corona pandemic. What can a psychiatrist say that people haven’t already got from the deluge of information and inspirational quotes that their friends have shared on social media? Be optimistic, don’t panic, eat a balanced diet, exercise, sleep well, maintain a routine, don’t give up hope, do yoga and meditate, learn something new – this will pass!

People say that we are all in this together. But we are not.

  • Those who can work from home and draw the same salaries as before are not affected much. Nothing has been taken away from them except the frills, the inessentials.
  • Those whose occupations need them to go out, like shopkeepers and domestic workers, who have dependent family members and survive on a steady income, find it hard to make ends meet.
  • Those whose business involves perishables are likely to feel doomed, like fruit and vegetable farmers
  • Those who have factories that can’t allow in workers because of social distancing norms can’t hope to recover soon.
  • Those who have been laid off as their employer is downsizing will find it hard to get another job. Maybe they could use the time to upskill?
  • Those who have lost jobs but have fairly substantial savings could husband their resources and wait out the pandemic.
  • Those whose work entails a lot of travel really don’t have a choice till travel safety details are worked out.

And so forth. There are so many realities needing different solutions.

I might understand and comfort patients, but can I offer them real help? Patients are fearful, anxious and vulnerable, especially now with all the uncertainty. As a medical professional I can’t even assure them that a vaccine will soon be available because that’s not certain at all. Sometimes a patient’s reality is so stark that my words sound like a bunch of hollow platitudes to my own ears. I can prescribe medicines but they’re only palliative and won’t solve the patients’ problems.

Right now, sitting safe at home, not much affected by the pandemic, I feel something akin to survivor guilt when I see images of the worldwide suffering this virus has caused. I have no solutions and it doesn’t look like anyone else in the world does either. If I had to counsel someone hit by this disaster my key word would be acceptancethat we don’t have as much control as we wish. This is something most disadvantaged people are aware of all the time. It’s us middle class Indians that are brought up to believe we can do anything and we should let nothing stand in our way. So we stubbornly try to slash through, rather than slowly make our way around, obstacles. Maybe we need to modify some of our personal constructs.

Our grandparents had a clear idea of their limitations and accepted that some things just befell them and they had to cope. They had to find strength within themselves and their community. They accepted that natural disasters and epidemics were not under their control. The idea that gods watched over them was also helpful in accepting the vagaries of life, including suffering, and I think this is a source of strength for a lot of people even today.

People used to save for a rainy day. There was always a nest egg to cushion the impact of a crisis. I think the current reliance on credit rather than savings has taken that away. Not only do people have no savings, they now have loans to repay as well, and no income. Should we re-think our approach to earning, spending and saving money when things settle down somewhat?

We seem to have lost direction as a species. We are living in the Anthropocene epoch that started in 1950, the epoch of human-induced global change. Imagine – an epoch named after the destruction we have caused! For delineating a new epoch, geological impact must be global, and has to be big enough to appear in the geological record of the earth. Like plastic pollution and nuclear testing are both part of our Anthropocene epoch. Maybe this applies to the global impact of the creation of the corona virus in a lab – if proven – as well.