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 Medicine. But we thought 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 focused on 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. 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.

born under an unlucky star

Parents feel immense grief and helplessness when too many things go wrong, one after another, in the life of their adult child. So they get him to come back home, to take care of him until things are better. They say he was born under an unlucky star.

What is Luck? This is what researchers who have been studying Luck have to say:

  • Luck is subjective, and a positive attitude can make you luckier.
  • Alert people who watch for opportunities can create good luck by grasping a chance quickly.
  • Lucky people tend to use serendipitous encounters cleverly, though they might say, “I got lucky”.
  • Lucky people vary their routines and thus increase the likelihood of serendipitous events.
  • Successful gamblers hone their betting patterns to get luck on their side. I don’t know how that might work, but that’s what they say.

Is there no such thing as pure luck that is controlled by Destiny alone? I do believe there is. Some people seem more prone to having things go dreadfully wrong with everything they try. I think the fear and negative attitude are a result, rather than the source, of bad luck.

I’ve heard people described as ‘someone whose touch can turn gold into mud’, the opposite of ‘someone with a Midas touch’. Some of them have gone from mistake to astonishing mistake, so you might wonder for a moment if they did create their own bad luck. But if you listen carefully to their story you can quite see that they couldn’t have done things differently in the circumstances of the time. Only in hindsight does it look like they could have.

As psychiatrists, we don’t usually make room for luck in interpreting patients’ problems, especially as people in India express it in astrological terms like, “Our astrologer told us he is going through saade-saatha shani”, and we know nothing about Astrology. We are trained to look at events in a patient’s life pro forma:

Problem

How did it start and progress

What was the immediate cause

Why does it persist

What has been done about it so far

Has such a thing happened before

Family history

Personal history

How is his current mental state

Though we empathise, our primary job is to objectively work out how best to alleviate his distress using solutions that Science offers.

Answering our questions can’t be easy for the patient. He can’t always justify the steps he took as he tried to scramble to his feet after each slide. He can’t explain why all his efforts have failed. He looks and sounds utterly defeated. That’s when the accompanying family member protectively steps in to say that he has had a lot of bad luck, and gives a number of instances.

His family is not going to abandon him when he is down and out. This impression could be something that inched into my mind subliminally over the years. Or, it is unconscious cherry picking I did out of a need to believe in human goodness, because I’m one of those people who read the newspaper every morning.

These cases give me hope that people still care, though things I read make me feel that we are done with all that, and now it is only about making the world high-tech, obviating the need for human beings and their troublesome emotions. Of course, I’m also aware that for every person who gets support from a loving family there are many who aren’t welcome back in the fold, but well . . .

With the corona virus unleashing a sort of guerilla war on us, a lot of young adults who are graduating from college this year are apprehensive. For many, confirmed job offers have been rescinded. Those who graduated last year and are in their first job are no longer certain what will happen to them. Young people who started new enterprises in recent years, and have not yet broken even, are worried. Those studying abroad are in limbo, online classes being a poor substitute for the vibrancy of real college life.

It’s bad luck that the corona pandemic intersected with their lives at this point in time. Many of them will suffer from anxiety and depression, and incipient psychotic illnesses will flare up in those at risk. It’s quite likely that many of these graduates will be jobless and need family support for an unpredictable length of time. This is pure bad luck and it’s not because of a negative attitude, a lack of alertness, or wasted chances.

They will eventually find a way around it. Some say “And this, too, shall pass away” was first carved by wise sages on a finger ring for an unknown Eastern monarch centuries ago. Some say the Eastern monarch was King Solomon. Some say Rumi originally wrote these words, and some say Rumi got them from Attar . . . Whatever their source, these wise words are our common inheritance, they belong to everyone, and are especially comforting for youngsters who might be feeling very unlucky in these locked down times.

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hikikomori

There are many lost kids out there. They are either dragging their feet in college for years after they are supposed to have finished, or have graduated but are disinclined to apply for jobs. Some of them take up jobs that are far below their ability and qualification. They use the paltry pay as pocket money and continue to stay in their parents’ home, neither asking for nor contributing anything.

What bothers parents most is the stonewalling, the refusal to engage in a conversation about it. The worst cases are where the kid stays holed up in his room with a laptop, does not come out even for meals, and raids the fridge at night.

There is no word in English – nor is there one in the DSM-5 ­– for this. However, the Japanese have a word for it: hikikomori, which roughly translates to acute social withdrawal. Hikikomori are adolescents or adults who have withdrawn totally from society, not leaving their room for weeks or months on end.

This phenomenon has been studied most in Japan because the country’s demography, culture and current job situation have apparently turned many youngsters ­– and adults – into hikikomori.

Who are these reclusive youngsters who quit mainstream life? This is a generalisation based on kids I have seen in clinical practice. A hikikomori in India is most likely to:

  • belong to a middle- or upper-middle-class family
  • be described as ‘sensitive’ and more inclined towards the arts, though he might hold a degree in science, business or law
  • have been sent to the ‘best’ educational institutions, hence expected to ‘succeed’ spectacularly by everyone, including extended family, a daunting situation that he is not up to facing
  • have done extremely well in school but poorly in college
  • have a recent history of failure, either academic or in a romantic relationship
  • not want to attend family events because he’ll have to explain why he is doing nothing
  • muse about whether all the slogging through school and college was worth it because life is pointless
  • tell you he’s reading philosophy and it makes more sense than the boring lectures in college
  • say that he sleeps during the day and sits up all night because it is peaceful

All these young people unhappily searching for meaning and direction, looking for peace, trying to hide from nosey relatives to protect their parents’ honour . . . It’s sad. Why is this happening to our kids?

One reason could be that they never got a chance to find out what they wanted from life because parents had set the course for them. To give parents their due, most see education as a means to a career and a steady income, not necessarily an exciting job. After all, they are funding it. The tussle over choice is now a common Hindi movie trope, and Indian parents are hopefully re-thinking Education.

Anyway, right now we have to do something about these apathetic kids. Without motivation there’s no impetus to go anywhere, get a job, do anything. So they stay in their rooms, numb, lost in their own world.

The apathy you see in hikikomori is not different from the apathy of a patient with a lesion in the prefrontal cortex, because that is the part of the brain that buzzes with ideas and energy to explore new possibilities.

One part of the prefrontal cortex gets you energised to make a plan; another sets the tasks for carrying out the plan; another executes it; another part monitors the execution; another part moderates your emotions. The foremost rounded part of the brain, the frontal pole, coordinates all of this, plus input from some other parts of the brain. So there can’t be any progress without energisation, the starting point for action. This is apathy, and it manifests as withdrawal. That is what neuroscience tells us.

Psychology says there is a deficit of Theory of Mind, i.e. difficulty understanding others’ intentions, and how their own behaviour impacts others. This is the same kind of deficit one sees in people with autism spectrum disorders and schizophrenia! So, the tendency to withdraw rather than confront might be a stable trait, that is, hardwired in the personality. Anyone trying to help a hikikomori re-integrate into the mainstream would have to consider this limitation.

There is no established way of dealing with hikikomori as yet. We probably have to connect with them, find out what energises them, light a spark and hope the other steps in the prefrontal cortex follow. We have to be supportive until they are ready to test the waters. This is not easy and it takes time. It might not even succeed. Meanwhile, we need to reset our priorities vis-à-vis raising children before we start giving these unhappy people labels or creating a new category in the DSM-6.

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an outlier

 

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A statue of Buddha in Phnom Penh with a rare expression of intense concentration, unlike the serene expression one usually sees on his face

I have no idea whether most people in the world are happy with the work they do, or what drives them to do what they do.

About fifteen years ago a doctor working in the same hospital as I requested me to see her son because she was worried about his career plan. The boy was a 23-year-old graduate from one of the best engineering colleges in India. He had rejected a paying job that he got through campus placement and chosen to join an organisation that worked for the upliftment of slum dwellers, for a small monthly stipend.

He was self-assured and calm during the conversation. There were no psychiatric symptoms at all and nothing to suggest a personality disorder. He believed that what he was setting out to do was right for him. He was also clear that he wasn’t going to be a financial burden on his parents.

Subsequently I met many youngsters like him and began to realise that it wasn’t uncommon for people of this generation to do something like that.

Most people get degrees that lead to jobs. They look for jobs that pay well and give them a few perks as well. They enjoy the office atmosphere, the company of co-workers, the work itself and the pleasure of an independent income. They look forward to the future. As I said, that’s what most people do.

So who are these outliers? When someone tells me about one of them this is how it often sounds:

  • There’s no rush for him to get a job as he doesn’t have student loans, because his parents are affluent;
  • He doesn’t have to earn and save up to buy stuff because his parents gave him everything even before he thought of asking – spoilt kid, born with silver spoon, doesn’t know the value of money;
  • He knows his parents have enough assets that he will eventually inherit, so he never has to work in his life;
  • He will eventually marry a rich girl and get money from the bride’s parents as well!

When I actually get to know the youngster I discover a wholly different inner world, where none of these are on his radar. They are the minutiae of his life that he barely notices. If he is charming and relaxed I might take a little time to make sure he’s not a clever manipulator skilfully pulling wool over my eyes. Instead, he is intense and rarely cracks a smile, and never attempts to please. There’s an air of urgency and earnestness about him.

I wrote about the brain’s reward centre in my last post. It is apparent that this boy’s brain doesn’t recognise a good job and its perks as a reward. His reward centre seems to urge him to do something that makes a difference to people in need: helping the poor seems more fulfilling to him than writing code.

Did the ‘mature’ defence mechanism of altruism develop naturally in him through childhood because he was raised in a peaceful home, without much conflict with his natural empathic disposition? That is, protoaltruism of parents giving rise to generative altruism in the child. Or is this pseudo-altruism covering up his issues? Altruism is a mature defence mechanism, but a defence mechanism nevertheless.

The concept of altruism has always seemed fraught to me. Sometimes I think it’s better not to look too close when some good comes out of someone’s altruism, though I wonder if it will ultimately harm the doer, but the doer will not recognise it as harm because – wait, is he a masochist! Okay, okay, that’s enough. I simply don’t go there.

Why did Prince Gauthama leave his kingdom, palace, wife and infant son and ultimately become the much-revered Buddha? His background and the sequence of events that led to his renunciation have never been a cogent enough argument to convince me that it was a sudden decision. Maybe it was brewing in his head for years before he took the step.

Perhaps something similar happens to youngsters like the boy whose story I began this post with. A kid gets into a professional college at eighteen in India. That’s too young. In the four years at university he might discover that he isn’t cut out for it. By the time he works out what else he would rather do, four years pass and he’s in the final semester. He decides he might as well complete the course and get the degree and figure his life out later.

How people’s brains are wired is a combination of genes and environment, the way you can create many shades of green by mixing different shades of blue and yellow, adding black or white – or even orange – to get any number of shades. The phenotype doesn’t automatically tell you the genotype. How did you get this particular shade of green in this painting? No idea!

The daily newspaper has been featuring one or two ‘Lockdown heroes’ everyday. If I were to ask these generous people why they did it they might say: “I like doing this, I like helping people.” I wouldn’t want to ask, “Why do you like doing this?”

Everybody’s insides look the same on the operating table – unless there is a diseased organ – and the depths of everybody’s mind might too. So anyone’s answer to “Why do you like doing this?” is bound to disclose self-interest and take away from the warm, fuzzy, happy altruistic feeling. So, “I like doing this” should be morally good enough to qualify as untainted altruism.

To come back to the altruistic kid in question, every engineering grad doesn’t aspire to be a Nadella or a Pichai. Sure, the idea takes a little getting used to for parents, because everything you read and hear says the opposite. Parents need to believe in their youngsters and support them in finding their niche. Usually nobody has the clinching argument in these heated family discussions, neither parents nor kid, because the moot question is what will happen to the kid’s career in the – unknowable – future.