puzzle in the park

It looked like a pile of junk when I saw it from a distance in Al Shaheed park.

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It still looked like a pile of junk when I went closer . . .

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. . . until I noticed this frame. . .

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. . . and looked through it, the way I was supposed to.

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There now, isn’t that perfect? 

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I guess that’s how it is with most puzzles in life!

 

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the desert beautiful

On Friday we left Kuwait city behind and drove southwest down Route 70 towards the Saudi border. There was a sand storm, not a severe one, and the sky was reddish-brown to the east.

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In some places the sand glowed golden in the ethereal light.

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We reached a wide expanse of desert where there were several cars parked haphazardly. We pulled over to see what was there. All-terrain bikes (ATV) were available on hire.

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People were riding them at top speed across the miles of flat sandy desert and up and down gentle slopes. We had a go too. Half an hour of riding at a good speed with no traffic (and certainly no traffic jams of the kind I’m used to in my home town Bangalore) and no kerbstones to set boundaries, was exhilarating. Liberating.

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Kids were amazingly good at handling them! And they were having good, clean fun outdoors too.

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We drove further to what we think is the Al Ahmadi ridge where we saw a family picnicking near their parked car, a common sight in Kuwait.

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There were a couple of people walking on the escarpment, deep in conversation. Nice place to have an interesting conversation actually.

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Some men had ridden the ATVs all the way up the road to the escarpment from the place where they were being hired out.

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We drove back down and took Route 70 towards the border of Saudi Arabia. The storm had driven sand onto the road and it was piled on the hard shoulder.

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It was a great day!

Note: No photo has been edited. This is exactly how the world looked that day.

 

 

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. I must emphasize that this is just how I feel. This may be irrelevant to other doctors, especially those in other specialties. Dealing with patients with psychiatric problems requires a different sort of engagement. A patient cannot bare his soul to a doctor he cannot trust.

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.

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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.

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

Kuwait City celebrates

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Liberation Tower built in 1996 to commemorate the end of the seven month long Iraqi occupation during the Gulf War of 1991

We’ve been living in Kuwait City for about a week now. Living because we’ve been given a furnished flat by the company my husband works for. Which means shopping for groceries, cooking, cleaning and laundry to do, unlike staying which means hotel, sightseeing and eating all meals out.

It’s a quiet, fairly spacious, flat in downtown Kuwait City. The sea front is just 10 minutes away on foot. On Friday evening – which is the weekly holiday here – we took a long walk along the beach. It was also the beginning of the Liberation Day weekend, the 26th anniversary of the end of the First Gulf War. A quarter century ago a lot of adults living here now were kids or young adults and have memories of the war. There is an awareness and appreciation of what it means to be free, and it comes through in the energy you feel swirling around, a feeling of relief and joy that conveys they don’t take freedom for granted. The parents’ indulgent expressions as they watch their kids run around freely seem to say “thank god they can have a childhood like this.”

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Families were out in full strength fishing, flying kites and having picnics. Nobody has picnics in Bangalore any more, so happy families eating biryani sitting together on sheets spread on the sand was a heartwarming sight that brought back childhood memories.

There was a cool sea breeze and the sun set in blue-grey and gold, understated spectacular, like discreet jewelry.

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It rained all Saturday, so we stayed indoors.

Sunday brought great weather and celebrating crowds out into the streets. Kids were dressed in the colours of the Kuwait national flag.

We were warned by locals that the kids would be hurling water-filled balloons at people on the sidewalk. We took the risk and had a couple of near-misses, but it was fun being out there among happy people. It was fun to see kids throwing water-filled balloons and squirting water at passing cars using water guns, thoroughly enjoying themselves.

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Kid with water-filled balloon

 

 

 

 

 

 

 

 

We spent the evening in the historic Souk Al-Mubarakeya market that sold everything from toys, fabrics, garments, vegetables, fruits and spices – to gold. Lots of gold.

IMG-20180226-WA0003We peeped curiously into a shop selling what looked like wood chips. The young owner invited us in for a sweet (in plate in the corner of counter in pic) and a shot-glass sized tumbler of Kuwaiti coffee that is brewed along with cardamom and boiled till it is reduced to a thick decoction. No milk, no sugar. The shop sold pieces of the bark of different trees brought from Assam in India for burning like incense in homes here. He told us he had lived in the US – mostly in LA – for six years as a student. He missed the burgers at In-N-Out the most, and in a burst of loyalty to In-N-Out, he disdained McDonald’s as “only for the homeless!”

The market encloses a vast square surrounded by small eateries. It was packed with diners and we found it hard to find a table. Mountains of food on huge platters kept arriving at tables, borne aloft and deftly served by agile and expert waiters. What a sight! (pic below)

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The evening ended with a short fireworks display with infants screaming in terror at the din. I remembered how my kids had cried in fear on their first Diwali and smiled to myself. Rites of passage . . .

The 26th is also considered part of the Liberation Day although 25th is the official one. That was the day in 1991 when the last few Iraqi soldiers who remained at the Kuwait airport had been vanquished.

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Yesterday was the 26th. We walked to Kuwait tower which is about 5 km from our apartment block. The scenes were exactly like the day before: kids, kids, kids running around everywhere, squealing and shrieking with joy; water-filled balloons splattering, water guns squirting, flags flying, cars adorned with flags cruising, happy families picnicking on the little grassy spots that must have been carefully nurtured as nothing seems to grow here except date palms and petunias!

In fact, on the way to Kuwait tower I was surprised to see a stray hollyhock plant in full bloom in a square little flower bed outside an office block. Was it planted and forgotten? Its stem was bent at right angles and lay parallel to the ground. What a pity. She could’ve been ‘the stately lady hollyhock’ if someone had watched over her.

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Anyway, it was another lovely evening both in terms of weather and the festive atmosphere. Walking back, we passed the marina where rows of dhows were tied to the jetty. It looked beautiful lit up the way it was. All of Kuwait City did, in fact.IMG-20180226-WA0021

Tomorrow the city will return to normal: kids will go to school, men will go to work and women will tend to their homes and children, I suppose. And the streets will be swept clean of the colourful debris of celebration, the rubber balloons gleefully tossed and abandoned.

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Singapore

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This is my third visit to Singapore and Singa-poh getting better only lah!

Gardens by the Bay is a new addition to Singapore’s tourist attractions that has come up after my last visit. It was worth spending an afternoon seeing all those beautiful flowers in the giant greenhouse designed by someone who genuinely cares about plants: Tan Wee Kiat, who stepped down from the post of CEO ten days ago, but will fortunately continue as adviser.

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It was the Chinese new year and there was the dragon dance, the light-and-sound show and all the other festivities associated with it in the evening. The place was jampacked with both locals and bus loads of tourists.

Another day, my husband and I went on a 10km hike through the McRitchie Reservoir trail. It was mostly in the shade, but not dense, because it’s a secondary forest that has sprung up on previously-farmed land. It was surprisingly similar to the part of the Appalachian trail hike we had been on in 2014 at the Delaware Gap in New Jersey. We saw an iguana up close a couple of times, an adult-sized one that silently slunk away, and a young, smaller one that hadn’t perfected her camouflage skills yet.

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There was one tree called the Terap that I found interesting because the leaves it produces when it’s young are so different from those it produces when fully grown. The young tree has large pentate, flamboyant leaves that look free and happy, while the adult tree sports small, sedate leaves of a conventional shape. Just like the difference between the imagination of small children and us adults, I thought.

Singapore does care about it’s trees, plants, animals and insects. On our way back we dropped in at the tiny butterfly park in the airport and managed to see a few that hadn’t yet snuggled under leaves to rest, though it was late by butterfly standards as per the notices in the park that said they would be active only between 10:00 am and 4:00 pm.

 

entropy

A friend sent me this link today. It’s about therapeutic writing.

http://www.allysonlatta.ca/interview/more-interviews/conversation-with-dr-james-pennebaker/

Now I know why I write the stuff that I write. Much of what I write is simply catharsis. I already know that most people are not interested in it, which is why I don’t talk about any of this to anyone! But I have to get it out of my system. So it goes here. I know this is a safe place because I’m not inflicting it on anyone, because they are not obliged to read it. There is that 1 nanosec wasted when they see it pop up on their screen and groan “Oh no, not her again!” I apologise for that to everyone right now.

This is how it usually happens: I read the newspaper in the morning (my generation still does). Something in it gets on my nerves and I have to write it out of my system because there’s nothing else I can do. Or, it triggers some old unresolved existential worry and I drift with it into an uncomfortable space in my head. I make myself a cup of tea and try to put the thought aside. It usually works and I move on to doing other things.

Then I might get a whatsapp forward from my friend whose husband is in the army. She has a stock of good scary ones like the water situation in Cape Town, data security compromised by linking something to Aadhar card, or some terrible news from the Pak or China border that she gets on her army wives’ whatsapp group. This sometimes sends me back to square one, and I might advance my mid-morning cup of coffee by an hour.

Today was a little different. I met my friend Jay at the lake on my morning walk and we walked together at his frenetic pace with me panting along, and he talked about how screwed up India is, and why do they keep calling it secular when it simply can’t be.

I drove back home ruminating on all that Jay had said. By the time I had breakfast and turned the computer on I was already in the zone, and in a hurry to get it out of my system. I hammered it out at top speed, and here it is. Warning: Not fun, read at your own risk.

Schisms >> entropy

  • Though the Constitution declares that India is a secular country, it’s hard for India to be one.
  • Secularism denotes a separation of religion and state, the government having nothing to do with people’s religions.
  • But the sacred frequently bumps up against the secular and puts the government in a spot.

Take the case of Goolrokh Gupta. A Parsi married to a Hindu, she was not allowed to participate in her father’s funeral rites because she married outside the community. This has been the norm for centuries in the Parsi community: people who leave the fold through marriage are excommunicated. Distressed, Goolrukh approached the Gujarat high court for justice. When the high court judgment didn’t favour her she took it up to the Supreme court. Meanwhile, my Parsi friend Rozbeh tells me that Goolrukh is wrong and the court has no business to decide she isn’t.

Our government can’t be called secular. It is very much involved with people’s religions. While some say that the government is promoting Hinduism, it could also be seen as promoting Christianity through the Joshua Project that I wrote about in my last post. It could even be seen as supporting Islam if you go by the minority appeasement politics it has indulged in for decades, and its recent noisy debates about triple talaq and pilgrimage rights of women. The newly added triple talaq clause in the nikahnama will hopefully prove a win-win situation for the government and the community. Then, the government has banned the Jain practice of santhara as being a form of suicide and Jains have taken out protest marches against the verdict. Last month the long-drawn-out Padmaavat row happened because of some Hindus trying to browbeat the government. How can a government stay secular in a country where religious beliefs keep clashing with laws and fundamental rights?

A lot of unrest in India is because of religious issues, including caste. The Hindu caste system is well known. If you google it you get 10,50,000 results. It is deeply entrenched. Nobody can hope to find a solution soon, or want to find one, because caste groups vote en masse and are useful to political parties as they are.

Schisms occur in every group, religious or otherwise. They almost work like castes, actually. Broadly speaking, Buddhism got divided into hinayana and mahayana, Jainism into svetambara and digambara, Islam into shia and sunni, Christianity into catholic and protestant long ago. Later, more splinter groups appeared.

Navdeep, a Sikh friend, told me just yesterday that there are castes in Sikhism too, something I didn’t know. My Sindhi friends, Kantha and Renu, say there are four castes among Sindhis, divided into higher and lower. In India there are even low-caste Christians who are converts from lower castes of Hinduism, ­­­called Dalit Christians. They have their own separate churches and priests and marry among themselves. My Christian friends, Nina and Rachel, deplore this as there are supposed to be no caste divides in Christianity, but candidly add that nobody in their families would marry a Dalit Christian.

None of this was intended to happen when each of these religions began. Every religion started off nice and pure, then got corrupted over generations like the first sentence uttered in a game of Chinese whispers, then split up into castes, sects or denominations. You see this happening in whatsapp groups too, often within days or weeks of their being formed, when you see a list of so-and-so lefts, and the group admin can’t do a thing about it!

It’s entropy. It happens to everything.

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I guess we all have our little nests where we feel safe – our communities – but if the tree falls, all our nests will be destroyed…

So, well, that’s the way it is in our country. We are a highly imperfect society, but we haven’t been doing too badly. We just have to keep resolving issues as and when they arise, and may have to lock horns with the government every now and then over some strong religious belief held by our community. ‘Secular’ is a borrowed idea, it simply doesn’t apply here.

Note: all friends and conversations real, names changed for their comfort should they happen to read this.

(Photo by Sandeep Vatsa)

 

things which make for peace

BENGALURU: Catholic bishops across the country have raised concerns over “…false messages of conversions are being spread on whatsapp and facebook to instigate communal violence.”

One of the bishops says:

“There are growing concerns and anxieties among Christian community members as the country seems to be going one-sided or on the verge of being affiliated to a particular religion.”

This is from today’s edition of The Times of India.

This is not going to happen. Newspapers may report a few incidents, and television anchors may hold highly-charged debates, but if you look around your own city or town, beyond your own little bunch of people, you can see that our country is doing well enough in terms of religious harmony. Nothing like the Goa Inquisition is going to be unleashed on Christians by the Indian government.

India is a pluralistic society. Most of my closest friends are Christians. We talk freely about religion as we accept each others’ belief systems. Nobody wants to instigate communal violence, though communal violence is often a fallout of a fight over something else.

Religion is not what it used to be fifty years ago almost everywhere in the world, and if you actually want to go by what is propagated via whatsapp and facebook, no religion can claim the moral high ground. I am sure people from every religious group, including religious heads when they were younger and not-yet-so-wise, are guilty of saying nasty things about some other religion, if not on social media, at least in their own drawing rooms.

When I think or write about religion it is always from the perspective of truly devout people who want to live right in God’s eyes. I’ve shied away from acknowledging that it is more of a political tool, and has always been one, because religion is sacred and empowering for billions of people, and I didn’t want to desecrate that by saying it is anything other than spiritual. In kind and open minds and hearts, religion is blessed, deeply meaningful and unifying. I believe that disparaging someone else’s god already makes you a bigot and your bias disqualifies you from judging other religions and preaching about god.

Religion is a power structure from a different era, like monarchy, and religious heads are loath to let go of power, just like European monarchies are. Apart from this, the need to increase the number of followers is also a practical consideration, so there’s some safety if there’s an internecine conflict involving religion, or even a world war, though the stated purpose is the betterment of the individual who is invited to join a religion.

As far as I can see, everyone is freely following his religion in this country for the most part. People have the freedom to propagate their religions too. I’ll give a single example. There exists a US-based project called The Joshua Project whose stated aim is to christianise all of India. The organisation was granted permission by the Indian government to operate in India in 2002. Its members are apparently even given special missionary visas.

Its activities have not been obstructed in any way for the past fifteen years as far as I know. I’ve often wondered how this project benefits India, and why the government permitted it, because I don’t see other countries allowing similar projects to hinduise, islamicise, sikhise, zorosterise, buddhisise or jainise their countries. It is possible that there are concerns in the Hindu community regarding this. In this era of fake news how do we know that the messages the bishops say are being spread on whatsapp and facebook are true or not?

http://indiafacts.org/joshua-project-study/

https://www.quora.com/What-is-the-Joshua-Project-How-is-it-impacting-India

To quote from The Washington Times, 15th Dec 2006:

“Officially, Christians comprise 2.3 percent of India’s more than 1 billion population. Unofficially, he insists, the number is closer to 8 percent”, he being a man called Thangiah who preaches in Bangalore. It’s only a ball park figure, but he wouldn’t say this without some idea.

Perhaps the bishops should look at the freedom Christians have in India compared to, say Coptic Christians in some countries, before making vague allegations directed against “a particular religion.” Please? This is as good as it gets, unless they are looking for Utopia. Let’s not destroy this country over religion. We’ve managed for a thousand years, so surely the bishops can address the issues raised by others and get on with it? Those people may have genuine fears too, fears that could be dispelled by the bishops’ answers.

“Let us therefore follow after the things which make for peace, and things wherewith one may edify another”( Romans 14:19). This applies as much to us now as it did to the Gentiles and Jews then, especially in the context of the Indian belief in vasudhaiva kutumbakam, which means ‘the whole world is one familyin Sanskrit.