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.

IMG_2170.jpg

 

 

 

 

 

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.

DSC02369

 

 

 

 

 

 

 

 

 

 

 

because the human brain is plastic

This is a heuristic take on therapy.

Listening to a patient is not very different from listening to a friend in trouble. As the patient tells her story, you feel her emotions and note her expressions, choice of words and factual consistency, apart from watching for telltale signs of physical illness. You empathise.

Meanwhile, the patient gauges whether you are able to understand her situation and emotions. It’s a two-way process, a lot of it non-verbal, during which mutual trust is established.

Psychotherapy sounds like something the patient passively receives. It isn’t. It’s a dialogue. The patient is a therapist’s ally because she knows herself much better than anyone else does. As professors often reminded us in college, “the patient tells you much more than she thinks she’s telling you, so listen.”

People see a therapist regularly for years for certain conditions, but I’ll leave that aside for the moment. I think therapy, by and large, ought to be brief and goal-directed. The idea is to help a patient learn to catch fish, not sell her some every week. For that I need to do some data mining within her history, personality and current situation and find her raison d’etre.

What keeps her going in life, what motivates her?

Does her motivation come from outside or from within? The type of motivation – external or internal – that drives people depends on their genes. I know that sounds discouragingly immutable, and that bothers me too. But if you look at families you know, or even at your own parents, siblings, aunts, uncles and cousins, you can see how that might work.

To give a simple example, you work either for a reward, or solely because you enjoy it. If your motivation is only internal and you love your work but are underpaid because you didn’t think of negotiating your salary when you accepted the job, you might feel shortchanged and get depressed and anxious. Therapy might help you discover that you need to develop external motivation as well.

But here’s the thing. By nature, you believe a job well done is its own reward. Asking for a raise is something you force yourself to do, something you’re not entirely comfortable doing. You might wish you weren’t wired that way.

Many of the sad stories of people who messed up their lives, and the happy ones of people who fought incredible odds to get somewhere in life, are algorithms that gave them a choice at every point. What motivated them to choose as they did?

A father tells me that he controlled certain personality traits with much effort long before his son was born, but the teenager now exhibits the same distressing traits and risky behaviour. What does it mean, considering only nature is in play here, not nurture, at least to the extent that the father consciously controls his behaviour? Traits – good and bad – are inherited and make you to do things? If this boy should grow up to be a ‘psychopath’, a court won’t let him off because genetic traits motivated him to steal, mug or kill. So therapy might prevent the predictable outcome.

Does learning ‘better coping skills’ and ‘developing mature defence mechanisms’ through therapy merely mean that you learn to exercise self-control and behave more appropriately, tucking away your maladaptive tendencies somewhere in a dark recess of your mind? Or does it change you at a deeper level? Or do people just grow up and grow out of certain attitudes regardless of therapy?

Then, there are people who are satisfied with who they are and what they have. Aren’t they motivated to be famous or acquire more stuff? Perhaps they have simpler ambitions and are easily satisfied. Maybe they are naturally risk-averse. Or wise. Maybe they don’t care about being judged. Or they may be detached souls who consider life a brief stop on a much longer journey of the soul. Either way, that’s how they are wired.

So, is it all down to the genes that control motivation? Where does volition come in then?

There is a tiny structure called the nucleus accumbens in the base of the forebrain. It’s called the ‘reward centre’. The nucleus accumbens is part of a loop that aggregates a lot of information that the brain receives. It is concerned with processing motivation, reward, choice, aversion, fear, impulse and pleasure ­–­ pretty much everything that makes you do, or want to do, anything at all. Your genes might decide what your brain considers a ‘reward’.

Does this mean that therapy changes something in this loop? As the brain is plastic, new neural connections occur every time you learn something. And these new connections possibly change the way you think . . .

Perhaps the new connections re-wire parts of the prefrontal cortex – the part of the brain that thinks and makes decisions – to respond in a more measured way to signals from the reward centre clamouring for gratification. So there is a biological basis for therapy as a treatment modality in Psychiatry.

As the nucleus accumbens also plays a role in reinforcement learning, the new way of thinking possibly becomes second nature. If this is so, the boy in the case mentioned earlier might be able to stop himself from mugging the man walking alone on a dark street if he has received the right type of therapy! Rehabilitation of juvenile offenders is a huge issue for which therapy focusing on each child’s unique reward system might be useful.

There’s so much published about how therapy works and how each part of the brain works. But I don’t think we know how they come together.

In my first year at medical college, I found Embryology fascinating. While it was easy to see how each organ and system was developing, I never understood how they started working. I still don’t.

IMG_1976
A page from my Anatomy record – FY MBBS (eons ago!)

For example, the sino-atrial node, the self-sustaining pacemaker in the wall of the right atrium of the heart, starts beating when the embryo is less than a month old. It starts producing action potentials (electrical activity) that start the heart beating, and this continues till the end of life! I can’t imagine how it does that, though I understand how voltage-gated ion channels in the cell membrane generate action potentials using energy from adenosine triphosphate.

And this is a single structure with a single function. Maybe the answers lie neither in biology nor in psychology, and we ought to look for them elsewhere. What I found regarding the sino-atrial node was completely beyond my comprehension. This is a study by mathematicians!

https://www.frontiersin.org/articles/10.3389/fphy.2013.00020/full

So I won’t pretend that I can completely figure out something as complex as what happens in your brain when you talk things over with another person! The point is that the human brain is plastic, and that gives us scope to change ourselves. We can free ourselves from the constraints of negative emotions like anxiety and depression – all of which are controlled by the brain – and let our spirits soar.

DSC02145

a sisyphean task

I keep coming across this statistic in the media: India has only 0.75 psychiatrists per 100,000 people. This is apparently the reason for countrywide neglect of mental health.

How can that be? We are talking about mental health here, not mental illness. Psychiatrists are medical doctors who treat individual patients suffering from mental illness, while other agencies are responsible for the mental health of populations. Substandard education, nutrition, housing and healthcare systems, unemployment, corruption, inadequate infrastructure and safety, disillusionment due to chronic mismanagement by successive governments, coupled with unattainable aspirations ­­– these are responsible for compromised mental health.

Let me put it another way. Physicians treat cancer, infectious diseases, metabolic diseases like diabetes, etc., but as an interdependent society, we are responsible for causing many of these diseases. Some examples:

  • Farmers using pesticides contribute to mutations in foetuses and cancer in adults.
  • The people who manufacture and sell sodas, fried foods and sugar-rich confections contribute to obesity and metabolic disorders, as also uninformed cooks who prepare food for others.
  • Unhygienic food handlers cause epidemics like typhoid.
  • Manufacturers of various goods, e.g. fabrics, cause sickness by dumping effluents into drinking water sources.
  • Almost all of us use automobiles irresponsibly, and also mindlessly buy and discard tonnes of clothes that are eventually burnt, contributing to air pollution.

Doctors can only do damage control, one patient at a time, and are not responsible for public health. A psychiatrist taking a patient’s history methodically rules out medical conditions as he goes along, before moving on to the Mental State Examination, so that organic causes are not missed.

Let me briefly clarify what is mental illness:

  • The innermost circle represents physical illnesses that present with psychiatric symptoms, like certain types of epilepsy, meningitis, encephalitis, brain tumours, vitamin deficiencies, memory disorders, intellectual deterioration, confusion, changes in personality, complications of diabetes, hypertension and other conditions, thyroid dysfunction, collagen vascular diseases.
  • The second circle represents illnesses that befall people, like schizophrenia, bipolar disorder, severe OCD. The causes are inherent, usually involving communication between different parts of the brain. A lot of Psychiatry is Neurology at a cellular level in the brain.
  • The third circle represents mental states like anxiety and depression due to a physical illness like the ones mentioned in the innermost circle, or life stresses, or an inability to cope. If the cause is psychological, symptoms are triggered by external factors, maintained by activation of particular brain circuits, and need short- or long-term psychiatric treatment.
  • The fourth circle represents behaviours of people who are dysfunctional for reasons that are a combination of nature and nurture. Some of their problems are psychiatric, but most are social or interpersonal.
  • The outermost circle is the one that keeps expanding. It is like the drawer into which you toss odds and ends that you mean to sort out some day. These problems are somehow seen as the responsibility of Psychiatry because the overt symptoms relate to the mind even though they arise from continuing, seemingly ineradicable, social ills.

Take alcohol addiction for example. A psychiatrist obviously evaluates a patient from a medical doctor’s standpoint. For instance, if someone is dependent on alcohol to sleep, I will investigate the cause of insomnia first and not label it alcohol abuse/dependence. Likewise, internet addiction might be the first obvious symptom of OCD. A young patient I recently saw for what his parents called phone addiction turned out to be a case of schizophrenia with comorbid OCD.

Alcohol addiction is considered a chronic, relapsing brain disease, and 50% of vulnerability is apparently due to genes. That still leaves 50% without a genetic cause. This study* by my colleague, Dr Vivek Benegal from NIMHANS, Bangalore, conducted for the government of India in collaboration with the WHO, details drinking patterns, harmful effects and management of alcohol abuse across India.

An excerpt:

Compared to 5 years back, there is an increasing availability and greater accessibility to alcohol (“It is much easier to get alcohol than milk!”), greater social acceptance of alcohol use and rampant and visible surrogate advertising (“No advertisement is needed for the sale of alcohol”). Increased prices have not lowered demand (“Now people are consuming more expensive drinks”).

Alcohol use is not considered a liability in relation to work efficiency. Festive drinking – customs (drinking during festivals such as Diwali or Ugadi) and traditions (use of alcohol at times of death, marriage celebrations and birth of children) – is more common than previously reported in India.

Narratives about heavy drinking of free alcohol distributed during elections at local, municipal and national levels were common.

Alcohol is easily available because you can’t ban it any more than you can ban sugar or butter saying they are harmful if abused. People are supposed to use them sparingly. Society as a whole is resigned to taking care of addicts because of addicts’ apparent lack of self-control. We go along with this when patients are brought in for treatment by anxious relatives, even though we know that this usually amounts to management of an episode rather than a permanent change in the patient’s outlook. It’s a Sisyphean task.

In my experience the most common reasons for this approach have been

  • awareness that alcohol abuse is a genetic disease in about 50% of abusers; also, that alcoholism is a depression spectrum disorder
  • depression and attempts/threats of self-harm by the patient
  • damage to organs caused by excessive drinking
  • empathy for parents/spouse desperate to get their kids/spouse off alcohol and get back to a normal life of responsibility
  • sympathy for the patient after hearing his story
  • knowing that people are unfortunately influenced by advertisers to see alcohol as an aspirational product, the way it was with cigarettes when the Marlboro man was the epitome of cool

Therefore, we focus on assessing suicide risk, managing physical effects like liver damage and vitamin deficiencies, treating depression, and attempting to support and counsel both patient and family. We can’t control the external stressors, the triggers. The multiple hospital admissions of patients who come for rehab have rightly been described as a revolving door pattern.

And there’s this too, from the same study:

Drinking continues to be mostly a solitary, under-socialised affair, mostly after work and outside home, and 50% of income is spent on alcohol.

The greater role of alcohol in domestic violence was recognised universally as also creating public nuisance:

“After drinking he purposely fights for small issues and behaves violently with family and others”; “After drinks, who is wife and who is children! They are beaten squarely”.

Ambivalent attitudes were also observed:

“My husband is a good person when not drunk but after drinking he will simply fight with me without any reason, scream at children and no more peace in the house”.

“(Husband) often beats children when he is drunk, otherwise he is such a good father”.

I have heard many such stories over the years from a significant number of female patients who present with symptoms of depression. Being married to an abusive alcoholic who is either unemployed or does underpaid freelance work makes them feel helpless. The cause of his problem ­– on the face of it – is unemployment, financial distress and lack of an education that could have led to a job. The root cause, however, could be genetics, his personality, priorities of his family of origin, or current circumstances. It’s hard to say whether it’s a mental illness, or lack of mental health. The poor wives accept it as kismet or karma.

As a doctor what is my role when an index patient is not sick? I wouldn’t prescribe an antidepressant for the wife as it makes no sense to pump chemicals into someone whose problem is somebody else! She needs support from some agency that doesn’t exist, and she needs her husband to be rehabilitated by a system that is either inadequate or doesn’t exist. I continue to be available and hope it helps.

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

If every departure from what is regarded as normal behaviour is given a clinical diagnosis the meaning of ‘mental illness’ will be diluted even more than it already is. While I accept that we are often the first point of contact for anyone in mental distress, I don’t think every patient who consults us has psychiatric problems.

The first fallacy about mental health is that it’s an absence of mental illness. But people can be free of mental illness, yet not have mental health.

According to the WHO, mental health is a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.

When there aren’t enough decent schools, colleges or jobs for people to realise their potential, when there are daily stresses like dense traffic, polluted air, flooded roads, unsafe sidewalks, a pervasive culture of bribery and rudeness, when you can’t work productively because, say, the internet keeps going off . . . you can’t have mental health. Of course, you can look at the positives, count your blessings and all the rest of the things that whatsapp forwards fervently propagate, but are they the real deal?

The long-term solution for meeting the mental health needs of a population does not actually lie in creating armies of psychologists, counsellors, life coaches, help lines, gatekeepers and what have you. I think the rot in society has spread far and deep, and the established systems that used to make people feel secure have been torn away, leaving them vulnerable.

Mental health is a public health concern, the health of entire communities. There’s a crying need for an overhaul of our national priorities. There’s only so much that individual psychiatrists can do because public mental health depends on government policies and a culture that makes it possible for people to have satisfying lives.

Removing roadblocks like the widespread corruption in our country ought to be the first step to achieving national mental health, not increasing the number of psychiatrists! This is the province of Applied Sociology or some other discipline, not Psychiatry.

As things stand, however, we need all hands on deck. Just as some of us need an accountant to help with our taxes, others need help in sorting themselves and their relationships out. People can’t always dig themselves out of holes they have fallen into, so someone has to hand them the tools. So we psychiatrists will continue to see anyone in mental distress. And concerned, empathic, people are welcome to help. Counsellors in India come from all backgrounds and, often, no particular qualification is needed as shown by these women in Tamil Nadu.

https://timesofindia.indiatimes.com/blogs/Globalpositioning/an-army-trains-to-tackle-mental-health-issues-in-rural-tamil-nadu/

IMG_0568.jpg

*http://nimhans.ac.in/cam/sites/default/files/Publications/WHO_ALCOHOL%20IMPACT_REPORT-FINAL21082012.pdf

 

 

this is all wrong

I am dismayed that Greta Thunberg’s detractors have weaponised her psychiatric diagnoses against her. Some have lashed out against her parents too. How did her medical information come to be in the public domain?

As a psychiatrist I have seen parents’ faces crumple when I’ve had to tell them their child has autism, schizophrenia, or some other distressing diagnosis. However gentle and careful I am, disbelief, shock and tears replace the hope on their faces in an instant. After a long painful moment, the shock slowly gives way to resignation.

So I can imagine what Greta’s parents must have felt when their child’s doctor gave the diagnoses: Asperger’s syndrome, OCD and Selective mutism. They had to support her. Without their support, she would have continued to be anxious, depressed and anorexic on the outside, and disillusioned, helpless, and dying a little each day on the inside. I don’t think anyone who has children can fault this child’s parents.

I personally believe Greta’s fears for the earth have a strong basis in science. Her fears for her future resonate with me because I have thought of the same things on behalf of my children, nieces, nephews, friends’ children and all the fresh, exuberant, youngsters that I see on the streets and on television, livening up the more jaded lives of adults all around the world.

As she has pointed out, we adults don’t have our entire lives ahead of us. While we’ve had it good, we have degraded the planet. They are the ones left facing a water crisis, polluted air, an overheated planet, melting glaciers, rising sea levels that destroy entire coastal communities, and floods, storms and earthquakes. Scientific knowledge to deal with these already exists. As Greta says, “I want you to unite behind science. And then I want you to take real action. Thank you.”

I am relieved she has taken a stand on behalf of her generation. But I would like to share what I have been telling myself whenever I started to worry on my kids’ behalf. I needed to tell myself this because I don’t have Greta’s courage.

  • Earth’s climate has always been changing. Climate alternates between being warm and wet, then cold, glacial and dry for several thousand years at a stretch. They are called Marine Isotope Stages. We have been in the current warm, wet period for the last 14,000 years, the Holocene epoch. We have data covering the last 2.5 million years. What’s happening could be partly a natural process.
  • Organisms on earth co-evolve with the environment – the Gaia hypothesis. Human beings weren’t always here during the 4.6 billion years of the earth’s existence. We are only 70,000 years old (though a human bone found in Morocco is estimated to be 300,000 years old). We somehow evolved and came to be, just as other species of Homo somehow became extinct.

The point is, nobody has been around long enough to know exactly what will happen to the earth towards the end of the Holocene epoch, whenever that comes. We didn’t come with an Instruction Manual on how to use Earth. But we can’t continue to plunder and brutalise our planet – that much is certain – morally and pragmatically, even if not on a scientific basis.

To get back to her psychiatric diagnoses, I am not sure if the diagnosis of OCD is still valid. It might have been a provisional one based on her unceasing rumination about the climate crisis at the age of eleven.

Perhaps she couldn’t process the discrepancies in adult doublespeak. There is often a conflicting subtext in adult conversation and behaviour, for example talking angrily about a neighbour at home and then greeting her with pleasure on the street. Children get confused when adults say something and do the opposite, more so if the child’s autism predisposes her to concrete, instead of, abstract thinking. As Greta said in one of her speeches to her parents’ generation, “You lied to us. You gave us false hope. You told us that the future was something to look forward to.” This, coupled with an autistic child’s intense preoccupation with a narrow range of interests, explains why she was obsessed with climate change.

An additional diagnosis of Selective mutism might be unnecessary because Autistic Spectrum Disorder itself would make it hard for Greta to indulge in social chitchat, unless she was a normal talker before. She has described how she went into a deep depression after she learnt about climate change and realised that adults were not doing anything about it: “I stopped talking. I stopped eating.” 

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

I watched Greta’s speech – “This is all wrong” – at the UN Climate summit two days ago. She made her point. But there are other problems in the world that she is completely unaware of, not only because of her age, but also because she lives in a country that doesn’t have these problems.

Sweden has a population of only 10 million while India, for example, has a population of 1.37 billion. These people need to earn and to live. They need jobs and money.

On 23rd September, when Greta was probably preparing her speech for the UN Climate summit, I read this in the same day’s issue of The Times of India.

https://auto.economictimes.indiatimes.com/news/industry/opinion-tackling-indias-auto-slowdown/71251927

One would think Greta Thunberg and the economist Ritesh Kumar Singh who wrote this don’t live on the same planet. He is thinking of how to help people with jobs so they can live, while she is thinking of how to keep the planet viable so they can live! These are the two viewpoints that need balancing.

Greta should know that her views have been taken into consideration by people of both her parents’ generation and her own. Things will not change overnight, but they gradually will, with a combination of individual and community effort, plus suitable legislation and international co-operation. The first step is acknowledgement, which she has got us to do.

In that sense, she has been successful. Maybe it’s time to go back to school. She can still keep an eye on things, continue to contribute her views and nurture the movement she started. The generation that takes the baton from us will devise better systems, I’m sure.

https://www.theguardian.com/environment/2019/apr/23/greta-thunberg-full-speech-to-mps-you-did-not-act-in-time

 

 

 

 

 

the guttering candle of trust

What is the difference between a doctor-patient relationship and a service provider-consumer one in the practice of Medicine?

I started working at a time when the latter didn’t exist in my profession. That was in the eighties. Good patient care was the only thing that counted, and making a diagnosis on the basis of history and clinical examination alone was a matter of pride. Ordering a hundred irrelevant lab investigations would have been considered a waste of patients’ money then. The attitude of patients, doctors and nursing staff towards each other was one of mutual trust and respect. Defensive medicine was unheard of. This is all true, not distorted by nostalgia.

Cut to today, and the question I started this post with.

When a patient meets me for a consultation for the first time it is with faith that I will understand and resolve his psychiatric problem. My conscience responds to the trust in his eyes and I feel an eagerness to help. A rapport is easily established. He tells his story. I write it all down, clarifying and processing as he speaks, finish the examination, and formulate a diagnosis. I answer questions about his symptoms and treatment, and give a prescription if necessary. I give him a rough timeline regarding prognosis, no guarantees. He accepts that. By then he is visibly relaxed, more hopeful. Supportive psychotherapy, a part of psychiatric treatment, is carried out in an atmosphere of trust and mutual respect, the patient’s for me as a professional, and mine for him as a human being. I spend the last few minutes of the session outlining the schedule for that.

When a customer/consumer/client meets me for a consultation for the first time he looks at me doubtfully, or with a forced smile, or even with frank mistrust. Then he sits down gingerly, pulls out his cell phone and shows me what he has downloaded from the internet, and tells me his diagnosis. Or he might hand me a sheaf of heavily highlighted print-outs. He’s done his research. Fair enough. “Anything else?” I say. “Can I call you by first name?” he asks. I know that this question is just a way of letting me know that he’s been sent to America a couple of times on work by the firm he works for (and this hint is supposed to convey something more about his place in the world), because this sort of familiarity is not the norm here, and being Indian, he very well knows it. He’s obviously approaching the consultation like a meeting between two people with equal knowledge, warily, as if a deal is being struck between a buyer and seller in which there is a risk of his being cheated.

The warmth and concern that I feel towards a patient just don’t well up in me when I’m faced with a consumer. And the mistrust in his eyes doesn’t engage my conscience at all. There is no rapport, only a job to be done. So I take the history and do a mental state examination in a neutral, clinical manner. Diagnosis made, questions answered, prescription given, effects of medicines explained. Check, check, check, check. Duty as service provider faithfully completed. Unless a positive change occurs during the session – which can happen for various reasons – it can’t be a very satisfying experience for either of us. And supportive psychotherapy is not possible because that requires empathy, something that is not generated in a buyer-and-seller type of transaction.

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

When I was a postgraduate student one of the prescribed textbooks was the Oxford textbook of Psychiatry, a regular-sized medical text book. In the newer edition, New Oxford textbook of Psychiatry that runs into two huge volumes, there is a chapter titled The psychiatrist as manager that wasn’t in the old one.

Regarding Managed care* the authors say:

  • Managed care is the use of business managerial principles, strategies and techniques in health care.
  • Essentially, it is a reform of health care from its longstanding not-for-profit business principles into a for-profit model that would be driven by the insurance industry or governmental bodies ruled by the same principles.

This is the difference between then and now, patient and consumer, doctor and service provider, as I see it.

Regarding Quality management** the authors say: Excellence relies on a few fundamental concepts:

  • Results Orientation: Excellence is achieving results that delight all the organization’s stakeholders.
  • Customer Focus: Excellence is creating sustainable customer value.

Who are the organization’s stakeholders? Who are the customers? Hospital owners and patients respectively, I suppose. So patients bring sustainable customer value to give delightful results to the hospital owners? Unless I’m taking this jargon too literally, something doesn’t seem right with this paradigm in terms of caring for sick people.

Using the word customer (= a person who buys goods or services from a shop or business) in place of patient (= one who is suffering) seems to trivialize his suffering, although taken literally, the patient is buying a service. It’s as if compassion, empathy, the patient’s dignity, and ordinary niceties no longer have a place in this highly commercialized world of healthcare, where sick people are mere commodities to profit from.

fd9213cc-e102-41d7-bc94-9a261d54f69a
(received as a forward)

Why has this happened? Is it plain greed? Is it part of the rampant corruption in our country? Or is it genuinely related to inflation? Is it because doctors run hospitals not in their capacity as medical people, but as businessmen? Or because people who own and run hospitals are not doctors at all? Could it be the numbing, desensitizing, faith-eroding effect of the large amounts of violence and injustice we all are exposed to in the form of news, television serials, computer games and movies? All of the above?

To get back to the point, people tend to give up on institutions that let them down too often. Adding to patients’ crisis of faith is public perception of hospitals as being more focused on profits than on healing, because incidents of patients being greatly overcharged for medical devices like coronary stents and knee implants, and consumables like syringes and needles are frequently being reported in the press today. Information about deleterious effects of prescription medicines, although often incomplete and misleading, is available on the net and people are more reluctant to take them. From what I hear from my own relatives and friends, people now have considerably lower expectations of doctors and hospitals, and some are openly cynical.

The trust between a doctor and patient — ­that was almost a given in the eighties — is now a guttering flame that I have to fan to life with almost every new case. While the blinkered juggernaut of allopathic healthcare barrels down its chosen route, patients are skipping out of its way by switching to alternative medicine for everything except the most acute medical problems. As a doctor I think they are throwing the baby out with the bathwater, but it’s going to be hard to convince them that many of us do abide by medical ethics. It is probably too late to win back their trust when it has reached a point where the government has had to step in with regulations to cap prices of drugs, medical devices, diagnostic services and treatment procedures, making newspaper headlines every day.

Of course, once we are totally replaced by Artificial Intelligence and robots, none of this will matter. Nobody can halt the inexorable advance of research in AI and people working in that field believe they are on to a good thing. Like driverless cars. Doctorless patients. Currently, computers can only analyze structured data, but it’s just a question of time before they are programmed to handle unstructured data generated by doctors’ observations and conclusions in individual cases. Sophia and her ilk can do the job. Doctors can be phased out. Going by the optimism and excitement in AI, I presume they will take care of sick people so perfectly that res ipsa loquitur will become redundant and the OED will call iatrogenesis an obsolete word!

Branches of study like Biomedical Engineering already exist in engineering colleges in India, and inter-professional programs are already part of medical curricula in many medical colleges in the US. So this change from the traditional practice of Medicine is bound to occur. This is the future, but thankfully not my future, so it has the feel of something viewed on a screen or imagined while reading a book. Anyway, I hope all this makes health care more accessible to the poor, that’s all.

* New Oxford textbook of Psychiatry, Vol 1, 2nd ed, page 45

** New Oxford textbook of Psychiatry, Vol 1, 2nd ed, page 43

our choices – and mental health

I feel like a Grinch writing this in the festive season, but the ‘Sale!!!’ signs are getting to me, because that’s all festivals seem to be reduced to. Buy, buy, buy.

I used to think advertising was about spreading information about a product, but now I know better. It’s about keeping us discontented and hankering for more. If we get tempted by advertisements and go broke there’s no one to blame – we did have a choice, right? So, if we aren’t alert, we actually have as much choice as a child with an open cookie jar within reach!

IMG_6701

While on the subject of choice, look at this: everyone knows that wearing a helmet while riding a bike can protect their heads in case of an accident. But nobody in Bangalore wore helmets even when the statistics were heavily publicised. In September 2015 a law was passed to force motorcyclists to wear helmets. Though it stands to reason, people didn’t take that to mean that the pillion-rider should also wear one! So in January 2016 another law was passed to that effect. Not that it always works (pic above).

IMG_6706Now something has to be done about the helmet-less little children who ride in front of the rider (as in picture above), or squeezed in between the rider and pillion-rider! And people who carry their helmets in their hands (as in pic). 

Ideally, everything should be left to choice and common sense, but it doesn’t work. So, when push comes to shove, the government takes over and decides for us. So there’s no choice, no absolute freedom really, to break our head in a bike accident. The same thing happens with freedom of speech, freedom to live legally in a country with the right visa, and other freedoms we misuse.

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

World peace. Human rights. Poverty alleviation. A government that has been voted to power in a democracy. NGOs. Philanthropists. All these words suggest that there are nice people making fair choices for humanity as a whole. Altruistic folks who want to mitigate human suffering and make the world a peaceful and equitable place. But how much choice do they have when faced with ruthless lobbies that influence government policies? Especially when the lobbyists are more important to the economy. Peaceful, contented people are not good for the economy, people who keep money in circulation are.

Think what might happen if an activist fought for our garment industry workers’ human rights in India. Or someone owning prime land in Bangalore refused to sell it to a builder with connections. They would get warning calls from unknown people, and then some. And a journalist trying to expose a business-government nexus that hurts ordinary citizens is always a sitting duck. No, these well-meaning folks don’t have much of a choice. Lobbyists always get their way because the government knows which side of its bread is buttered.

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

Moving beyond the local, the US had a choice to not sell US$110 billion worth of weapons to Saudi Arabia. But then, I guess big companies like Lockheed Martin, Raytheon and Boeing would have lost out on profits, and their employees been out of jobs. To me, this seems like a good reason for selling, apart from having the Saudis fight their proxy war against Iran in Yemen. Also, perhaps the possibility of lucrative contracts to re-build the destroyed countries, something that usually follows use of weapons of mass destruction.

Choices involving thousands of innocent lives are made based on material gains of some sort, and don’t seem to have any moral underpinnings. That’s how it seems to me, an ordinary Earth citizen, a mere observer of events. Words like ‘big business’, ‘big government’ and ‘big pharma’ make me uneasy because the choices they make can have seismic effects.

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

So, is there a place for teaching children to be good girls and boys in today’s world? Believe me, I faced this dilemma all through my children’s school years. By trying to raise children to be good – as ‘good’ is generally understood – are we setting them up to be misfits or wimps and fail in today’s world? Pure 24-karat gold is too soft to be fashioned into jewellery. Lesser metals like silver, zinc or nickel have to be added to make it 22-karat, for it to be crafted into durable jewellery. I think I just hoped my kids would pick up the silver, zinc and nickel on their own in adapting to the world.

Or have we pragmatically scrapped the whole business of goodness and switched to simply teaching them consumerism? Looking around Bangalore’s shopping malls, massive hoardings and the monstrous garbage heaps all over the city, I suspect this is what is happening.

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

What bothers me is that Earth Overshoot Day was on 2nd August this year, and has been coming earlier every year. That means, on 2nd August our resource consumption for this year exceeded Earth’s capacity to regenerate them! Ideally, this date should be at the end of December. It was 20th October in 2005, 21st Nov in 1995 and the third week of December in the mid-eighties.

When I look at all those cotton clothes in store windows, I wonder how much water and labour it takes to grow and pick cotton in India. It takes about 35 cotton-bolls to make a tee shirt (a boll weighs 2-6 grams, a tee shirt about 150 grams), I’m told. Why is there such a glut of clothes in the world? What happens to unsold clothes, those left over after discount sales? Actually, I find everything is in excess – like electronics, packaged foods, shoes, LED lighting in malls, cosmetics… I know people are happy to have a wide choice, and these industries generate jobs for millions of people – so is it all right for our generation to overuse Earth’s resources? And is the guiding principle of shopping greed, and not need, because it is tacitly – no, quite overtly – encouraged by our way of life?

I’m not much of an activist. All I do is follow the reduce-reuse-recycle mantra, compost part of the kitchen waste, and stick to need-based shopping, an adaptation of the Hippocratic oath, ‘first, do no harm’. And I send a bag of vegetable and fruit peelings from my kitchen to my maid’s neighbour’s cow every day; at least one cow in Bangalore gets to eat a little bit of something nutritious, rather than discarded plastic bags.

IMG_4234
A common sight in Bangalore despite a ban on plastic

I am aware that there are people actually doing things that make a difference in small and big ways all over the world. Vigga Swensen (Denmark) and Justin Bonsey (Australia) are two people whose initiatives I came across recently. Vigga’s is a little tricky as some people may balk at the very notion of dressing their babies in used clothes. Justin’s initiative could be adopted in cities anywhere: http://www.abc.net.au/news/2017-06-16/ditching-disposable-coffee-cups-war-on-waste/8625018

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

The WHO defines mental health as ‘a state of well-being in which an individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community.’

The WHO also acknowledges that ‘poor mental health is associated with rapid social change, stressful work conditions, gender discrimination, social exclusion, unhealthy lifestyle, risks of violence, physical ill-health and human rights violations.’ We, the ordinary citizens of India, are plagued by every one of these.

Can universal mental health ever become a reality considering the individual choices we make in our daily lives, and the choices that people in government make, whether it is Kim Jong Un, Xi, Maduro, Trump, Netanyahu, Nigel Farage, or the politicians who have led India for the past seventy years? Moreover, will the economy survive the impact of contented people who will not buy expensive branded clothes to feel more confident, join pricey gyms for the ‘perfect’ body, eat at fancy restaurants to upload photos on facebook, buy the latest cell phones for bragging rights, and so on?

18-August-2018

Kudos to these people!

https://timesofindia.com/city/bengaluru/no-to-plasic-these-banks-lend-steel-cutlery-to-reduce-waste/articleshow/65447000.cms

22-August-2018

Earth Overshoot Day was on 1st August this year 😦

30-July-2019

Yesterday was Earth Overshoot Day – three days before last year’s 😦

20-Nov-2020 : Earth Overshoot Day was on 22nd Aug this year due to COVID. Good!