दरख़्त वाला भूत

क्या आपका कभी किसी भूत से पाला पड़ा है? मेरा पड़ा है. या यूँ कहिये, मेरे कुछ हमसफ़र थे, जिन्हे ऐसा ही अनुभव हुआ था. पेश है एक व्यक्तिगत संस्मरण- एक सच्ची घटना. बोर्ड ऑफिस भोपाल का वह बिना हाथ वाला भूत दिसंबर १९९१: सर्दी के दिन थे. उन दिनों मैं भोपाल स्थित कस्तूरबा हॉस्पिटल में ओफ्थल्मोलॉजी विभाग में हाउस अफसर हुआ करता था. मेरे सभी साथी गाँधी मेडिकल कॉलेज परिसर में स्थित हमीदिया हॉस्पिटल में कार्यरत थे. बस इक्का दुक्का मित्र मेरी तरह बी एच ई एल इलाके में थे. ऐसे में सप्ताहांत में मैं अपने मित्रों से मिलने दूसरे परिसर में स्थित होस्टल्स में जाया करता था. कॉलेज में तनोज और मैं... बस दो ही जुनूनी थे जिन्होंने इंटर्नशिप में आकर साइकिल खरीदी थी. मेरी लाल और उसकी मैरून - दोनों ही हीरो हॉक. इसी साइकिल से भोपाल जैसे पहाड़ियों के शहर में मैं कहीं भी पहुँच जाया करता था . उस रोज़ भी सभी मित्रों से मिल कर मैं देर रात, लगभग १० साढ़े दस बजे अपनी एक हॉस्टल से कस्तूरबा हॉस्पिटल वाली हॉस्टल की ओर निकल पड़ा. कमला पार्क, रविंद्र भवन से होते हुए रंगमहल सिनेमा... उसके बाद न्यू मार्केट ... सब कुछ ठीक चल रहा था. मैंने साइकिल का रूख अपैक्स बैंक की ओर मैं रोड १ की ओर कर दिया. यह क्या, पूरी सड़क अँधेरे में नहा रही थी. रोड डिवाइडर्स पर कभी कभार कोई ट्यूब-लाइट पल भर के लिए आँख मिचोली कर जाती. लेकिन हाँ, जैसा भुतहा कहानियों में अक्सर होता है, उस रोज़ पूर्णिमा का दिन था अतः चाँद पूरी रोशनी बिखेरा रहा था. अपैक्स बैंक से डेढ़ किलोमीटर दूर अचानक मुझे छह या सात लड़कों का एक दल मेरी तरह साइकिल पर सवार देखा. कुछ ही देर में मैंने स्वयं को उनके करीब पाया. इससे पहले मैं उनसे आगे निकल पाता, मैंने उन्हें आपस में कुछ इशारे करते देखा. लड़कों ने आपस में बातचीत का अंदाज़ बदल दिया. उन्हें एक मूक श्रोता मिल गया था. "... अरे, यहीं तो था.." एक ने कहना शुरू किया तो सब के सब सामंजस्य पूर्ण ढंग से किसी कहानी का ताना बाना बुनने लगे. "... भाई साहब, आप अकेले जा रहे हैं?" यह इलाका अकेले जाने के लिए ठीक नहीं है" मैं निर्विकार भाव से उसी गति से आगे बढ़ता गया. "... भाई साहब, आप रहते कहाँ हैं?" दूसरे ने कहा. स्वाभाविक था लड़कों के दिमाग में कुछ न कुछ खुराफात जन्म ले रही थी. ओर इस खुराफात का निशाना मैं बनाया जाने वाला था. "... कौन मैं?... बोर्ड ऑफिस के पास..." मैंने भारी सी आवाज़ बनाते हुए कहा. मैंने काली जैकेट पहन रखी थी. मेरी साइकिल पर मेरा गज़ब का कण्ट्रोल हुआ करता था. इसलिए देर तक झुक कर साइकिल चलाने के बाद अब मैंने अपने हाथ बाँध लिए थे और संतुलन बनाते हुए साइकिल आगे बढ़ रही थी. "...हाँ, ठीक है... लेकिन बोर्ड ऑफिस के पास कहाँ? ...कौनसी कॉलोनी में? "... कॉलोनी? कैसी कॉलोनी? ...हमारे ज़माने में तो बस यहाँ जंगल हुआ करता था. बस यूँ समझ लो, मैं यहीं रहता हूँ...बोर्ड ऑफिस के पास एक दरख़्त पर." मेरी आवाज़ अब तक और भारी हो चली थी. संयोग की बात... अँधेरी सड़क पर एक ट्यूब-लाइट क्षण भर के लिए फिर जगमगाई. अब साइकिल रोशनी में ठीक से देखी जा सकती थी. लेकिन मेरी काली जैकेट में बंधे हुए मेरे हाथ नहीं. "... अबे, ...अबे ... उसके हाथ..." "... उसके हाथ नहीं हैं!" एक लड़के ने दूसरों को चेताया. सभी ने देखा, 'उसके' हाथ वाकई नहीं थे. लड़कों की साइकलें धीमी हुईं, फिर वहीं रूक गयीं. मेरी साइकिल सहज गति से धीरे धीरे उनकी नज़रों से ओझल हो गयी. ------------------------------------------------ कैसा लगी आपको यह सत्य कथा? उन लड़कों का क्या हुआ? क्या वे भी मेरी तरह यह प्रसंग अपने यार दोस्तों या बच्चों को सुनते होंगे?

Doctors decry the proposed National Medical Commission Bill's proposal

Few years ago, a cardiologist denounced a suggestion in a Phone in programme of a TV channel, when asked whether there was any truth that "bottle guard" (lauki in Hindi) juice could have medicinal value in certain cardiac ailments including congenital one. The doctors stand was quiet justified. The (currently abortive) bid of the Indian Government to maintain a national register of all licensed medical practitioners and a national register of AYUSH (ayurveda) practitioners, who have take up a six month bridging course was widely opposed by doctors. This bridging course would then allow these alternative therapist to practice the medicine that is taught in modern medical colleges. However, medical fraternity needs to introspect and accept what it does to (embrace and) endorse dubious therapies. Founder director and chairperson of a leading cardiac center in Southern India once spoke to a famous God-man and asked him to comment what in his opinion caused congenital heart ailments. I shared some of his other views on CHDs on my face book group on Congenital Heart Diseases: https://www.facebook.com/groups/138375512446/ few months ago. Do god men really know everything? Can any human be Omniscient? Surely, the doctor who discussed this issue with him, knew more about Organogenesis, embryology and cardiac ailments. Another, leading cardiologist form North India offers hollow alternative therapies in the name of holistic medicine. Not just that, many corporate hospitals (as well as Private Practitioners) tie up with all kind of alternative therapists to create a referral system for them. You can not oppose NMC Bill's proposals, if you otherwise endorse those practitioners. You can not have an "On Off relationship", a marriage of convenience between Medicine and mysticism, occultism and alternative medicine. Disclaimer: The purpose of this is not to touch upon religious feelings. Its sole objective is: myths must not eclipse rationality.

Read this if you are a doctor practicing in India

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The story of an uncooperative child

"..... Oh, why is the baby crying? Can't you hold her properly?", yelled the doctor.

The mother, holding her infant widens her eyes anxiously, and pulls the baby closer to her. Meanwhile, her two palms move over the thighs of the baby and eventually stiffen around the legs of the baby lest they hit the "busy doctor" again.

"..... Oh, can't you hold your own child properly", said a visibly fuming physician. He then stared the spouse of the woman, who is equally perplexed as the woman. The doctor eventually has to be more explicit regarding what he expects from the husband.

"Hold her head! Fix it, so I can peep in his eyes!"

The husband tries to do as directed.

But the baby has his own way: he tries to relentlessly shake off the the shackles so that she can settle the score with the physician herself.

OK, I will see the child later! Never seen such an uncooperative child....", the doctor leaves the chamber and subsequent words are not heard.

The parents have no inkling as to how much time they need to spend before the doctor can see the child again.

The parents come out in the waiting lounge. The child is happy in the cosy comfort of her mother's lap. The husband mulls, look around and then manages to slip the sheet that had the questions he wanted to ask the doctor.

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Indian doctors the world over imbibe the local medical culture effectively and efficiently. Back home, however this kind of scenes are not uncommon.

Who needs to be trained, the doctor or the child? or, the hapless parents?

As a doctor, who has provided and required medical services and has been on either side of the doctor's table, I feel, many Indian doctors have de-sensitized.

What if your child has *%#@* % or any other major illness, I see hundreds of these kind, even worse! That is the undeclared statement.

The doctor easily forgets that the parental anxiety doesn't have to be proportionate to the gravity of the diagnosis! ... or the prognosis thereof.

I agree, an Indian doctor back home sees more patients than his western counterpart. Mostly he has no control over the number he has to see. But there are also others who may not be as busy, but still continue to frown.

Trust me, as a health service seeker, I have felt uncomfortable asking questions pertaining to a dependant's health. It may look strange since I am a doctor: there ought to be no communication barrier between me and my professional colleagues, you would say.

But the communication between two doctors may not always be unhindered.

I would keep in mind, the number of appointments he has. His body language may give a clue to it.

Then there is the Hippocratic oath.

"Thou shall not accept any fee from your colleagues", implies the oath.

Sometimes this means, the colleague has limited freedom to access the doctor. I wonder if it would be better to access the health system as an ordinary person who knows nothing of medicine! ... Who pays the consultation fee and walks away.

I am sure I am not the only one who has occassionally felt uncomfortable seeking a medical consultation for a dependant. This is evident because many of them who visit my clinic want to pay off in other ways.. may be through gifts...

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Back to the scene in the begining of this post:

Do you think, a child as old as 1 or 2 year can be "un-cooperative" (or co-operative for that matter)?

A child as young as that can be ignorant, but un-cooperative.....? Does your own child always co-operate, when you give him pills or syrup?

The onus to examine an un-cooperative child is upon the "experienced" doctor that you are.

Need feedback from you.

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Epilogue:

The above incidence actually happened few months ago in an Ophthalmic clinic. I identify with the plight of the couple because, we have been through similar circumstances as parents. I take this opportunity to thank the colleagues who have been extremely patient while answering our queries.

No insult is intended to any particular physician in person.

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World arthritis day

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Today is world arthritis day.

Arthritis is a very common ailment. And its a chronic one. So there are bound to be dissatisfaction with whatever mode of therapy you have been advised. Patients with arthritis move from pillar to post but a once for ever solution evades them.

Does this necessarily mean any alternative to your on going drug is going to be better?

Believe me, if you are an arthritis patients, that chronic ailments such as this open flood gates of opportunities in all countries - developed and developing alike. The modus-operandi of these proponents may be different. Those in the western hemisphere use the cyber route while the most primitive of these opportunists offer services by the road side in developing nations.

A typical dissatisfied patient in an oriental country might be fascinated by newer (read "faker") ways of treatment. He may also be tempted to search the net based knowledge as to what is relevant overseas.

In contrast a western counterpart sometimes decides to explore the mystic remedies himself: oriental medicine ought to have an answer!, so is his thought.

Sometimes such people travel east word to countries such as India or China.

Sadly, as I said in earlier posts wonder drugs do not exist here.

What can you do about this:

Where ever you are,

(1) Try to have confidence in the ability of your doctor, If you don't trust him, may be change your option.

(2) Go to a doctor who listens and answers ands not just "treats". Many of your unfounded worries can be addressed. Many unknown facts may also appear that you need to know about your illness.

(3) Don not replace the opinion of your doctor with that of a friend, relatives or a cyberconsultant or portal including this one. Treatment of arthritis is highly individualized.

(4) Look for a rheumatologsit (they are scarce in countries such as India) or a good physician.

(5) Let the doctor decide what is best for you: A parallel voice e.g. another patient describing his illness) is not for you.

(6) Don't be too scared when you come across a leaflet that describes the side effects of your medicine. You need to be aware of those symptoms so that you can report them to your treating doctor. This information is not for you to take a decision or to stop the medication.

(7) Most arthritic disorders typically have a morning stiffness due to overnight lack of activity. The answer to breaking it is in resuming the activity and not resigning to your pain.

(8) Drugs if indicated are to be taken so that you may avoid a deformity.

(9) Exercise is good and recommended but do not pick up something without the approval of your doctor.

(10) Be happy: Arthritis has psycho somatic factors - feeling down may worsen your suffering while being cheerful would help relieve the symptoms.

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Nasir Khan's shadow

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Few days ago, I watched a man called Nasir Khan who acted in a Hindi Movie called "shadow".

The interesting part is while there have been plenty of sighted actors (Nasiruddin Shah in Sparsh was one) who played the role of a blind person, this guy played the role of a "sighted guy" and even went on to do all his stunts.

I admire him and wanted to share on this blog.

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Diet and health: The “ill effects” of jackfruit

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Origin of medical myths

Superstitions prevail in Science. At least sometimes.

It is believed that Pythagoras sacrificed an animal to appease god after he succeeded in proving his famous theorem in geometry.

I have heard that some scientists from Indian Space Research Organization chant mantras on the eves of launch of vehicles that carry satellites.

Some of these things may not be superstition in true sense but simply a ritual.

I am not talking of these rituals.

I intend to address the superstitions prevailing in medicine or medical practice rather.

Patients often associate their symptom to a particular event preceding it. For instance, “I got flue because I ate…..”

In India, patients often ask you what food they should avoid. There are conditions where a particular food or ingredient may be desirable or avoidable. Everyone knows what to avoid if you are diabetic or hypertensive. Then there can be food allergies, indigestions. For instance Celiac disease patients need to avoid a protein in wheat called gluten.

A doctor may ask patients to avoid leafy vegetables and other vitamin K rich food materials if some one has a high risk of thrombo-embolic phenomenon which can lead to the formation of clots within the vessels. These patients may still take these food materials but they would have to enhance the dose of anti-coagulant drugs they are taking.

All this is justified and there is Science behind that has been understood.

However, what would you do if a condition does not require any dietary restriction or addition but a patient insists and would not go without such an advice?

I finally advised one such stubborn patient to avoid “Jackfruit pickle especially if old” in a remote and arid area of Gujarat where you actually don’t get Jackfruits at all! Nevertheless, my patient returned happily… fully satisfied! He returned with good post operative vision and attributed it to strict adherence to my advice.

If you see this woman propagating the message that consuming jackfruit affects the visual recovery after a cataract surgery, don’t blame her. It’s me.

As you see the origin of some of the medical myths lies in such pieces of advice we give.

Sorry poor innocent Jackfruit!

Don’t worry; I am going to have you in my dinner tonight.

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Doctor, how long will it take....

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What do you think, how long will it take ....

(A) me to die?

(B) me to turn blind?

(C) my regurgitation to progress from moderate to severe?

Questions like this are almost universal in the minds of patients with chronic illnesses.

Why do they originate and how can one answer them?

They originate because the communication between a doctor and a patient is incomplete. When we doctors tell you the prognosis (i.e. the likely outcome) of a medical scenario, we are talking statistically, which means given a large group of patients, most would tend to behave along the expected lines. But statistic does not predict the fate of an individual in the same group!

This incomplete communication between a doctor and his patient leads to a lot of avoidable anxiety.

Finally to answer all such questions, I use the following illustration:

My hair is 10 percent grey (in reality the grey colour is barely visible!), can you tell me how long it will take it to be 100 percent grey?

You can't predict that.

So why worry?

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Depressed due to illness? Shine like a comet!

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In my previous post, I mentioned a doctor who was misdiagnosed to have leukemia.

A reader might wonder what is so inspiring about this tragic story. There is.

I have seen a comet only twice in my life. Halley’s comet orbits sun every 76 years. It was last seen in 1986. I had seen it with my bare eyes. The other one was the comet Hale-Bopp.

There are moments in life when one doesn’t know what lies ahead. Everyone no matter how fortunate or otherwise he or she is faces such days.

Prior to 1986, the Halley’s comet was seen in 1910. As everyone knows, there are myths about these poor celestial objects.

The world would end!
The life on this planet would cease!

These were some of the myths associated with the Halley’s comet. A report in a Hindi Magazine in 1986 told me that several people gathered together in a mosque in Tehran and committed a mass suicide in 1910! In a similar stand, several people gathered in the basement of a building in Vienna to face a common predicament.

The myths and panic reappeared in 1997, when the comet Hale-Bopp was seen. There were talks of an alien aircraft closely following the comet. A religious cult “Heaven's Gate cult” encouraged people to commit suicide as it would ensure a good “after life”.

So in a way, I like most of us survived one or two major comets!

I wish the doctor I mentioned in my post had opted for a timely second opinion and bounced back to life. However he chose to be eclipsed slowly.

The message: Don’t let any thing eclipse you, try to shine like a comet.

Lisa Ray diagnosed with multiple myeloma is shining. She did so at the Toronto film festival recently.

Best

Happy Alzheimer's day!

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He lived with a disease he never had...

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Year 1986, Gandhi Medical College, Bhopal.

I had just moved in one of the hostels as a second year MBBS student. Located adjacent to the beautiful Upper Lake in Bhopal, it was a lovely place to be in. However those days ragging used to be rampant in medical colleges and most of the time we remained cocooned inside our rooms. One of the largest rooms was occupied by a grand senior who entered the college in 1968 and had still not cleared his MBBS! There was no college regulation that could be invoked to "see off" such perennials.

He had been there for time immemorial: Although unlike another grand old man, he hardly spoke to anyone, we were still a bit scared to be around his room. I saw him exchanging words with only a cook who prepared food in his mess.

This guy was not always like this. "Legends" circulated about him. He had topped the first professional examination of the MBBS amidst a group of 140 students.

Then came the biggest blow of his life. He was (mis)diagnosed to have leukaemia!

Years passed by. There was no counselling available for him.

He awaited what we call death in vain for years, untill one fine day, he was declared not to have leukaemia at all!

However life had changed irreversibly for him. I believe he had been a drug addict.

A year after I graduated, he also finally managed to get his degree.

Dr. D.L Aren was an MBBS in around 1991 or 1992. He soon perished not because of leukemia but a generalized debilitation as a consequence of his addictions and alcoholism.

A beautiful life came to its end after a miserable journey.

Dr. Aren lived with a disease he never had, but ironically met his freedom from illness in his untimely death. I normally change the names of the subjects in my posts, but call it whatever, this as a delayed obituary to a man who would otherwise be a great doctor, but for a medical error.

Block A where he lived is now a girls' hostel.

The garden is there, but the "selfish giant" of O. Henry who unintentionally prevented us (kids) from playing there is not there.

You are missed Dr. Aren!

Manish

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(Please read my epilogue to be posted separately in a subsequent post.)

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One of their kind

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While Mr. George Abraham, the founder of WBCC, himself fancied being a fast bowler like Dennis Lillee, here is another man.

Born In Zimbabwe, Dean Du Plessis is blind since childhood: He reportedly had retinal tumors which I believe to have been retinoblastoma.

This chap uses the stump microphone and his accentuated hearing to occupy his seat in the commentator box. He has covered test matches, one day internationals and even 20 20 matches!

Aren't they one of their kind?

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Look, who is playing cricket!

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I had an opportunity to meet George in 1998 at Venu Eye Institute. Senior consultant Dr. Anil Tara had introduced us. He called him George, so did I. I saw him, while he heard me.

As I learnt much later, Mr. George Abraham had founded the World Blind Cricket Council (WBCC) and was the man behind the world cup for the blind. His visual status was a result of complication of meningitis that had affected his optic nerves.

I was subsequently assigned the task of screening a bunch of young cricketers from seven countries. They all had varying degree of visual handicap; some were completely blind.

In my ophthalmic career, I have come across all kind of people with disabilities and also normal people feigning a disability. Examination these players was a different ball game. Their disability had to be graded so that an appropriate mix of these guys could be included in a nation's team.

A guy from New Zea Land was a tough nut. He had retinitis pigmentosa - so the disability as such was beyond doubt. However the decision to designate him as an individual with highest grade of disability was tough and required knowledge about his visual acuity as well as field of vision. After much consideration, I gave him a benefit of doubt and he was regarded a player with higher degree of deficit. I followed the news of the world cup with an extra interest: What if the Kiwis had an extra advantage with this player. Final was played between South Africa and Pakistan and I was a relieved person.

Mr Abraham is reported to be working on Indian Blind Cricket league. My good wishes to him and the players.

With my chronic ailment, should I really marry…? Why not?

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That is what my answer to the question asked by my patient is.

To my mind Rahul should be more open, if not overtly looking to hunt a partner. He has every opportunity to share the nature of his illness to his prospective spouse whether she comes a natural way or through an arrangement as is the case in India for most.

How should he do it?

He should do this in an open straightforward manner without sounding either guilty or insecure about the future of his relationship. Even people without an ailment have heart breaks. His potential spouses should have a right to approve, choose, or discard him. A person contemplating marriage to some one like Rahul, should give enough time to self so that one doesn’t marry out of “pity”.

Similarly, Rahul should prepare himself for a negative response. Remember, his potential spouse had that right even if he had not had the medical problem… Her right needs to be respected.

I have heard of people concealing their status even those who are carrying HIV virus or have full blown AIDS! for the sake of marriage. Their spouses, whom they infect in due course have been abandoned after they pass away. Not only this, the stigma of AIDS, takes its toll as well. There are reports where a wife has been held responsible for the disease, even though she contracted it through her deceased husband.

Message to Rahul:

Open up…
Look for a potential mate…
Share honestly…
Don’t feel rejected! Every human has a personal dignity, so in true sense, a human rejection is simply a subjective perception.
If a proposal is turned down, it saved at least two lives….
And finally even without the ailment, your marriage could fall apart…
So be happy.

Every single person can be married any moment.
But every married person can’t be single so quickly!

A single person’s life is better than that of a person in a wrong relationship.

Looking forward to your marriage invitation, Rahul …!

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Doctor, with my chronic ailment, should I really marry…?

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Rahul (name changed) is 27, a tall, handsome guy with hazel colored iris pigment. Self employed and runs a placement agency. He was a juvenile glaucoma patient who had been operated for intractable glaucoma when he was only 9 year old. He says, his visual status (which is significantly reduced in terms of the visual field), is known only to two persons: his doctor (that happened to be this blogger) and himself. His family obviously knows about his ailment; however to everyone else he is a crazy guy who owns a bike, has access to his father’s car but for reasons best known to him, avoids driving either of them.

Rahul is not alone. Many glaucoma patients are forced to lead a restrained life due to visual field restrictions. As I said in a previous post, some countries even have legislation that (rightly) prohibits them from driving.

Unaware of his actual visual status, his parents are behind him. They feel it’s high time he “settles down” with a suitable bride.

Around a year ago, he sought my views about this. Marriage in India, unlike in most western countries are arranged, unless someone falls in love, in which case there may still be a lot of family drama because of multiple differences in caste, religion, region, language and financial differences.

Nevertheless, the question Rahul has raised, I believe must be shared by many others irrespective of which part of the world they live in. A patient with a chronic disease, physical limitation more often than not relives these restrictive factors and puts up a lot of anxiety not directly linked to the ailment itself.

So Rahul discussed his reasons for avoiding a marriage:

“I don’t have a girl friend, whom I could marry. (He probably closed the doors for a relationship because of the potential impact she would have to bear!). Even if I had, I wouldn’t want to ruin the life of someone I loved. My parents are pressing me to tie the knot, but the question is why should I marry and cheat a person I have never known….” he says.

Effectively, he has ruled out marrying someone he could have been in love with as well as others whom he wouldn’t be in with.

What do you say to this question?

I would post my answer shortly.

::

Can herbal drugs evolve to be integrated into modern medicine?

::


This is the story of a wounded soldier named Hussein Khan. Critically injured, down with high grade fever and thirsty, he decided to drink dirty water from a pond. The water was too bitter, but since his thirst was unquenched, he decided to have a mouthful of it “one last time”, or so he thought.

Hours passed and he woke up again. The fever was gone. A new dawn looked ahead!

This water was no magic water. It turned out that the bitterness was due to the bark of trees of cinchona that were abundant in the region. Quinine is derived from the same bark. Effectively, the soldier had survived malaria in a war torn endemic zone! Quinine the first effective anti-malarial drug is seldom used now but its analogues such as chloroquine are.

Quinine is not the only drug of herbal origin used in modern medicine. Digitalis derived from fox glove, atropine derived from atropa belladonna are some other examples of drugs that had herbal origin, but thanks to modern research, they are now seen as “allopathic drugs”. From anti malarials to anti malignancy drugs and immunomodulators, one can cite many examples.

All these wonder drugs are not free from side effects in either crude or refined form as any student of pharmacology would tell you. It’s just the difference between the right dose and wrong. Digitalis used in cardiac ailment is also known to offset the rhythm of the heart! Quinidine an isomer of quinine has serious cardiac toxicity as well as ocular toxicity that is shared by its synthetic analogue, chloroquine. Cyclosporine, an immuno-
modulator is used by renal transplant recipients, but is known to be a nephrotoxic drug itself.

So the notion, that only ‘modern drugs” have side effects and others are free needs to be readdressed. Only a placebo would be free from side effects, but it would have no desired effect as well!

Having said this I would like to address a discussion begun by a fellow Ophthalmologist as a comment on my previous post: What about the potential therapeutic effect of a herbal drug that someone prescribes for viral hepatitis, in Maharashtra, India? I would say, if the observation is correct, someone needs to design a study to see if any substance present in its extract indeed has an anti viral property!

But until such substantiation is there, the herbal drug is at best only a “potential” or “candidate” drug.

A proper research on such drugs is in every one’s interests, especially the patients who squander a lot of money on alternative medicine. According to my personal estimation, the money spent on irrational treatment (including irrelevant use of proven drugs) outweighs that spent on real drugs judiciously.

So the mantra remains: Know about medicines, explore the credentials of a doctor. Its your body, don’t use it as a test tube.

::

Short cuts in medical research: a fallout

::

Few years ago, I hospital in Noida, UP, India had a press release about a "new procedure" that rejuvenated a diseased heart. The approach was based on use of "gene therapy" and employed delivering a gene to the heart so that new blood vessels could "sprout out" in place of the diseased ones that were blocked. This was kind of a medical first in India.

An alternative to this procedure would be a coronary angioplasty surgery, whereby a graft would be inserted to resume blood circulation to a diseased heart.

Soon again the hospital was in lime light again albeit for wrong reasons this time. The procedure was not pretested either on animals or in a pilot study. I am sure research groups across the world would have been working on the same line, but did not pursue it so speedily as did this group.

As a result of gene therapy primarily targeted on heart, there was sprouting of blood vessels in the retina of these patients, a process know as "neovascularization" to medical retina experts and ophthalmologists. Clinically it was like eliciting a diabetic retinopathy in those without diabetes!

Such a scenario could have been averted if the desire to be among the pioneers could be curbed.

What is a patient supposed to do if the research itself has proprietary or academic interests?

I seek views of readers and hope to answer through a subsequent post.

Manish

::

Spurious researchers try to evade "intrusion"

::

Year 1996.

Place: Eye department of a leading hospital in Hyderabad

I had been to the twin cities to participate in an Ocular Immunology and Uveitis symposium at LV Prasad Eye Institute. I had heard of a group led by a Russian doctor who was engaged in research on retinitis pigmentosa. After having participated in the symposium, I had some spare time before I could board a train back to my home town. I decided to visit this hospital.

I met a young lady who was a receptionist there. The Russian doctor was not there, however an Indian associate was. I told the receptionist that I would like to meet the group that was engaged in research on RP. She moved in. I could hear the entire conversation from the waiting area.

Receptionist: Sir, an Ophthalmologist has come who wants to know more about your research on RP.

Doctor: What does he want to know....

R: About what are you doing in RP....

D: Tell him to go away....

R: .... (silence)....

D: OK, if you can't, send him in....

R: (c0mes out) Sir, he is calling you.

D: (with a conceited smile) Yes please, How may I help you?

I (MJ): Sir, I wish to know more about your work on RP, and if you recruit fellows interested in basic sciences and research...

D: No, in this hospital we don't.

MJ: (Since I had heard the entire earlier conversation) So there is no reason for me to stay any longer, right...?

D: Yes.

I left the room.

Later I understood the group was injecting an injection they called "encadem", an indigenous research products prepared from the eyes of owls! Owls tend to have good scotopic (night) vision but are nearly blind in photopic (day light) conditions. I felt, It would be interesting to understand the physiology of an owl's visison, but a crude extract.... in an injectable form..... how could it be helpful? It could elicit an immunological response but would not achieve any thing...

I was and am skeptical of the authenticity of the work. There is no published report by the group.

I understand the message in this post is clear. There has been an incidence when an RP patient sought my advise regarding a study protocol (cleared by institutional review committee). That indeed was a wise move!

No short cuts in medicine

::

In a previous post, I mentioned the rigorous process a candidate drug is subjected to before it gets a nod by drug authorities.

India is currently seeing a burgeoning clinical research industry. The institutes that offer such courses claim that India is going to be a global hub for R & D in clinical research and thus there are going to be ample opportunities in clinical research.

However given the kind of country India has become, practically anything can be spurious here! So there are a few concerns I have:

(1) Is it possible that the great Indian hub becomes a hunting ground where foreign multinational companies bypass stringent policies adopted in their host nation(s)?

(2) Would it jeopardize the interests of Indian patients who may be lured by the "foreign component" in the tag?

There have been cases where Indian hospitals or doctors have indulged in dubious practices just to be in the lime light. I am sure many would recall, a doctor couple got their teenager son to carry out a Cesarean section on a pregnant lady just that they could announce him to be the youngest person to have accomplished the "feat". Currently another government hospital is in news for wrong reason: a team in a hospital based in Madurai, Tamilnadu, India carried out over a dozen breast surgeries (lumpectomy) for breast growth in a "record time" of three and half hours!

So if you are a patient with a chronic or incurable disease, don't jump and participate in a clinical trial. Seek advise.

More to follow....

::

An eye opener for a glaucoma patient

::

Mrs. Shreya Pathak (name changed) is a known patient of primary open angle glaucoma and high blood pressure. She had been on drugs and eye drops that managed both.

One fine day she decided to give a road side quack dealing with alternative drugs an opportunity to "handle" her.

The "doctor" (quack) gave a powdered substance in small packets made of paper to ingest. It tasted bitter. He claimed it came with his indigenous "research". The amount was fairly large to ingest as she recalled. Nevertheless, she had it or else it would mean "inadequate faith" in his ability.

Soon after she fainted on way to her house. her husband took her to a nearby doctor, who found her to have a very high blood pressure. He also advised some blood tests. Even the blood sugar had shot up like any thing! She was not a known diabetic but the random blood sugar was over 210 mg %.

The physician however succeeded in settling her in a day or two. However she still had significant pain and redness in eyes. So on day four she visited me.

Her intraocular pressure was 36 mm Hg in right eye and 38 mm Hg in left eye.

Clearly her glaucoma was uncontrolled as well.

What could have possible gone wrong?

I do not know for sure. However one possibility was administration of a very high dose of steroids.

Whatever it was, is history for Mrs. Pathak now: but it was, as she puts it an unforgettable day in her life. She vowed never to return to the quack and the likes ever again.

She visits my clinic regularly for routine eye check up.

::

What do you need to know about drug research.

::

As a patient of any chronic ailment you need to know that every medicine that reaches you comes through a strenuous process that begins in a lab where a molecule is "designed" to unlock a physiological mechanism in our body that has gone awry. A drug then enters animal studies or sometimes "in vitro" studies where the effect & side effects of the drug is seen in animals and in cultured human cells. Once through, comes a pilot study where the drug is assessed in a small group of healthy volunteer &/or selected patients. Multi centric trial involving several patients from multiple centres spread across countries or even continents comes next. This eliminates the bias the original inventor may have.

Repeatability of an observed effect or side effect is also determined through these trials. A safe dose that would ensure the desired action without any side effect is also worked out.

This whole procedures aleady consumes several yearsbefore the safety profile is worked out and many a times potentially promising therapies disappear before they reach you!

As a person belonging to the scientific community, I find it painful to hear that "modern drugs are bad since they have side effects!".

Medicine would not have advanced thus far if a rationalist approach had not been taken up since the begining. In contrast, all kind of alternative drugs remain mystic and occult. The knowledge pertaining to these also known to "a chosen few", some of them claiming to be "practicing" over generations! A gullible patient religiously takes them for months and years and the disease is either cured on its own (some diseases affect only certian age groups or are influenced by certian external conditions that may improve or disappear), or the patient perishes. In either case, it's advantage, "occult thearpist!".

What do you take for your ailment?

Something prescribed by a qualified doctor or a quack?

Beware.

To be continued.....

Do wonder drugs really exist?

..

Alternative medicines thrive on "hopelessness"

Let us recall my brave HIV positive patient discussed in the following story:

http://rendezvous-doctorsblog.blogspot.com/2008/11/man-versus-virus-story-of-brave-aids.html

This lady had CMV retinitis an opportunistic infection of the eye. She had been seen by us in Chennai and was heading towards Trivandrum in 1995. She had heard of a "miraculous cure" that involved some heavy metals for HIV and AIDS that turns a patient negative on an ELISA test for the HIV virus.

I am not sure she planned to go to this chap out of firm conviction or simple helplessness. There was nothing she would loose by that trip, she must have thought.

My consultant told her, there was no way, one could be free from virus by using such wonder drugs. After she had left, he asked me if I could think of any way, one would have a negative ELISA test that has been positive earlier. We had no information if the lady implied a negative "western blot test" as well.

There was one way, I thought the result of ELISA could be skewed if a heavy metal could break the disulphide bridges in the immunoglobulin molecules that hold the heavy and light chains together!

We do not know what happened to the lady and her HIV tests subsequently. In all probabilities she is not alive today as she already had a full blown AIDS then.

But of course, had the miraculous drug worked the "doctor" (read quack) and his centre would be famous the world over by now!

These kind of terminally ill patients fall prey to all kind of gimmicks. Unlike the patients who have good medical prognosis (and who survive) these patients have been adequately "counselled" to understand their predicament. They would never sue the quack... nor would their relatives in case they do not survive themselves.

The duration of treatment of these ailments also tends to be prolonged. So there is an ample scope to mint money through them.

Did you hear of the wonder drugs prescribed by a quack (now in jail) in Rishikesh, India, who claimed to have found a cure for epilepsy?

He is behind bar now.

That is the logical conclusion of these stories, but we seldom get to hear this as there is no way to bring them to justice in most cases.

However a dental college owned by this thug still runs.

Moral of the story:

Suspect anything practised stealthily by people who make tall claims!

The original question: Do wonder drugs really exist?

Yes, chloroquine was once a wonder drug when initially discovered and when malaria was rampant.

Penicillin the first antibiotic to be discovered was since there were no effective ways to combat infections in the pre antibiotic era!

Rheumatoid arthritis: Can you really avoid deformities

A lady known to have Rheumatoid arthritis for 9 years came to me after an interval of four years. She had already developed a severe form of dry eye called "keratoconjunctivitis sicca" when last seen.

There had not been much difference but for the facial swelling and visible deformity of fingers.

When asked, she revealed that she was under care of a neurologist and in addition taking medicines prescribed by Baba Ramdev.

"Do you have relief with his medicines?", I asked.

After a thoughtful pause, she said, "yes", skepticism evident on her face.

"But as per records, you did not have these deformities in the small joints of fingers when I saw you last!, And you have been taking herbal medicines....".

"Yes, but I understand there are no side effects....".

"That's right, but there has not been any effect either!", I said.

I explained why it was essential to be under care of a rheumatologist, who would have prescribed disease modifying drugs, and also why she needed to go for physiotherapy to prevent other deformities.

The modern medicine as I said in a previous post are maligned for having side effects. But whatever is known about those side effects is accepted and published. So it is a very transparent .... .

I hope chronic patients would understand that. Instead of having a false sense of well being, let a good doctor be in charge of your problems!

When deciding your choice between drugs prescribed by a rheumatologist and those by someone advocating alternative medicines, please understand that the goal of treatment should not be mere control of pain but prevention of deformity as well.

Happy recovery!

Retinitis pigmentosa ( I ) : Visually challenged employ sighted ones

Nearly fifteen years ago I came across an elderly man with a young son who had an ocular ailment called "Retinitis pigmentosa (RP)". RP typically affects the eye sight in such a manner that night vision is affected , field of vision is gradually reduced and eventually reduced to a tunnel vision. In order to understand the problem of a patient with progressive RP, you are advised to role two papers in the form of a tunnel applied close to your eyes and then try to cross a busy road.

They had been to dozens of ophthalmologists in India and carried a heavy file weighing more than at least a kilogram of papers. It took me nearly 10 minutes to browse through their correspondence with doctors, clinics, those providing alternative medicines as well as those making tall claims about restoring vision (without even knowing about the ailment).

I was impressed with the spirit of the father who left no stone unturned. They even corresponded with " Ophthalmic clinics of North America" thinking them to be a clinic while in reality they are a publisher. I wish everyone could have that kind of never say die attitude.

Wherever I have gone, I found the patients of RP harbouring hopes despite often getting relatively poor attention in Ophthalmic clinics. Its a low priority area for amny since it does not fetch surgical revenue. Some of these have left their contact details so the I could tell them about any subsequent break through.

Among the remarkable patients of RP, were two sisters in mid thirties. I met Them around 7 years ago. They are no longer sighted, but instead of feeling dejected they emanate hope for others. Of course when they saw me in my clinic, they wanted a miracle, which I can't perform. Nevertheless they left on a positive note when I told them, they were better than many of us as they ran a school and thereby "employed" many sighted individuals like me. There school is somewhere in Almora, in the hills of Kumaon in Uttaranchal, India. I have been through the area, but never had a chance to locate it.

I know the future of kids at that school is in right hands.

Quadriplegic wins right to die

An Aussie quadriplegic has won his right to die in peace with dignity.

This chap has had two accidents that rendered him in his present shape, where he is on a wheel chair, unable to move any of his limbs.

Since Australia does not approve aided euthanasia, no body would assist him. This means he has been granted a permission or right to stop feeding.

In a way, the court has facilitated his cause by approving death by starvation. No body knows how much time it would take. This appears akin to "santhara" the Jain religious ritual of voluntary death by fasting, once the purpose of a life is thought to be over.

The unanswered question is: if in any case death by starvation is imminent now, why cant one go a step ahead and approve assisted euthanasia?

I am neither a supporter nor an opponent of euthanasia. That needs a larger debate. The purpose of this blog is to encourage people to say yes to life and not otherwise; nevertheless, the court verdict in this case made me ponder. What do you feel?

Disclaimer

The author does not support either santhara or euthanasia in its current form especially in a country like India, where one could have a forced - Santhara. Please refrain from judging what the authors views would be from this writing.

Chronic ailments: What is the role of alternative therapies ( I )

Hi,

Do alternative therapies really work?

Dr. Christian Bernard the South African cardiologist, who pioneered the first heart transplantation suffered from Rheumatoid arthritis. After this feat he was famous the world over. Concerned people across the continents poured in a lot of suggestions for his rheumatism. All were essentially “alternative medicines”, some claimed to be practiced “over generations” by the “prescriber”. I recall, keeping an onion in your pocket was one of them, as mentioned in a book by Dr. Bernard.

I intend to answer one basic question here: why does a person seek an alternative therapy.

One reason is, the mainstream therapy failed to live up to patients’ expectations.

The other reason is the chronicity of the disease itself.

Next is a “negative image” imparted to modern medicines: “they have too many side effects” any one using alternative medicine would tell you.

Modern medicines emerge after a rigorous multi step operation that includes trial on animals and human volunteers. Whatever side effects are encountered, are documented and admitted by the medical fraternity. They are there for everyone to see.

Another reason is a highly populist strategy adopted by those who practice alternative medicines. Do you come across a well groomed doctor claiming to cure azoospermia, inability father a child due to lack of sperms? This and many other ailments are claimed to be treated by the quacks! It is because of this populist measures that the likes of Baba Ramdev have survived in India, but strangely enough, you find such practitioners even in countries like the USA.

The last and a very important reason is people’s belief that miracles exist: something will appear out of no where and they will be cured. Gullibility out of despair!

I will follow up these views with more in subsequent posts. Dr Bernard was overwhelmed with the global concern for his ailment, but certainly did not practice these

Educate yourself before falling in for alternative therapies!

Text to Speech: Is that a potential solution to the academic pursuit of the visually challenged students?

Hi

Thanks Odiogo!

Thanks David for the information on the "Text to Speech" engines.

As an Ophthalmologist I get to meet several bright but visually challenged students; or, put it this way, I get an opportunity to diagnose their ailment. Their parents some time seek help or information on teaching aids. I have told them about the computers and the softwares that help the visually challenged: by providing a larger image of the text on the computer screen, by creating a sound every time a word is typed by the stroke of a key board.

Last such question was raised by the father of two siblings, a boy and a girl, both suffering from a variant of "heridomacular degeneration".

However, as I said in a previous post, the information regarding these does not trickle down in this country.

Any way, if the work is indeed in progress, on the TSS in India, it may be possible for a student to download the text from may be either CBSE's web site or any other site that may provide the course's contents. If this is pasted on a personal blog (a visually challenged student's personal notebook), it may be possible to hear them!

If someone from "the telecommunication and computer networking group (TeNeT)", IIT Madras, can comment on that possibility?

Manish

Myths in medicine: an anecdote

It was a sultry day in Rapar, a small taluka in far off Kuchch where I had been sent as an Ophthalmologist about fourteen years ago. A small town with a population of over 40,000 already had one ophthalmologist before I moved in as per my contract with my new employers in north Gujarat. I must have operated upon quite a few people there for cataract or glaucoma when this old chap consulted me. After an elaborate examination, I passed on my advise, “You have an operable cataract, & you better don’t delay the surgery, otherwise you may have a raised intraocular pressure. An old man of over fifty with more wrinkles over his forehead than those on his “kuchhi turban”, was immediately taken aback. It took me another ten minutes to cajole him into giving his consent for a cataract surgery that was eventually scheduled three days later.

I was a nervous beginner on the dee day. The guy was so fussy- any complication & he would be behind me, I thought. Careful I was & as Almighty might have wished it, we, patient & I landed safely. The surgery was followed up by regular visits as I had instructed him. Finally the day came when I was supposed to prescribe him glasses. I was delighted to procure a 6/6 vision- something akin to a score of 10 on gymnast’s bar.

I proudly explained it to him, “Kaka tamari nazar saari thai gai”
(You have had a great surgery, good enough to restore a perfect vision!).

Kaka gave a mystic smile, took out a peacock’s feather hidden somewhere in his turban & said “aa hatu naa, mare dhore saheb, etle”.

(It’s because of this peacock feather that I had been wearing all these days, sir!).

He happily pocketed a free sample of an eye drop, kept aside for him & left my consultation room. I was left aghast & enlightened that it was neither my surgical skill, nor the Almighty’s grace but the feather of national bird that restored his vision!

Odiogo, Odiogo....

....how do you do this?

Few years ago I had an opportunity to visit the National Institute for the Visually Handicapped (NIVH), Dehradun, India. They have a huge collection of cassettes in their audio library. One elderly lady and a gentleman lend their voice to the literature available as text. Any one who is visually challenged can get a free access to the library. What one needs is a certificate of disability. Consequently, the cassettes are sent across & collected free of postal charges by the Department of Post. The NIVH does send a list of cassettes to listeners. The scheme is impressive, but the question is, how many are aware of it. Like most government run benevolent schemes, there is no publicity of the facilities offered.

The second issue is the kind of knowledge that can be audio-transcribed. Can it cater to the needs of visually challenged students? Or is it mostly meant to entertain the elderly ones who would otherwise read the religious texts? I don’t have an answer to that.

If someone does, let me know. The address of NIVH for those who are not aware of this facility and knows someone who can benefit is:

National Institute for the Visually Handicapped (NIVH)

(Under Ministry of Social Justice & Empowerment)

116, Rajpur Road,

Dehradun 248001

India

Another potential way to enhance the access to knowledge could be an internet browser, which could convert the written text to voice. I am not aware if this exists or not.

Lastly, I wish to thank the odiogo.com for lending their voice to my blog. I hope someday, this could help some one with a piece of relevant information!

Odiogo, how do you do it? Is it a manual process or you use a word synthesizer like the one designed for Dr. Stephen Hawking? I wish some one undertakes such a task in India!

I would be interested to know!

Thanks odiogo!

Manish

IAS aspirant gets a cochlear implant

A guy clears the prelims of the Indian Administrative Services - the IAS. Not once, thrice, gets rejected twice and gets a costly cochlear implant to attain the minimum "auditory criterion" to qualify.

Result: Imminent rejection. The screening centre doesn't have an audiometry facility. The onus presumably on the candidate to prove he qualifies!

Few years ago a Calcutta girl was detained in her class tenth examination for poor attendance. She skipped classes to avail chemotherapy for a blood malignancy. The Principal was a woman, a stubborn one.

I am sure if this cochlear implant guy gets an opportunity to be a "public servant" as they are called, he would be better to give a patient ear to the masses.

Would the government understand this?

Lots of reservations for people in this country. Even for physically challenged ones. But why should they be "accommodated" in a category of special people? Why not have a truly equal opportunity scenario?

With that, he would qualify any way.

Don't you think we need to change?


Manish

Can you accomplish this?

He happened to consult me for some eye problem.

He did not have any in his normal eye.

The abnormal eye had drifted downwards due to a damaged floor of the orbit, the upper eye lid is perpetually closed, the eye ball partly in what anatomists and doctors call "maxilla" - upper front part of the cheek, adjacent to the nose.

After seeing him, I asked him what did he do?

"I have a bicycle repairing shop, where I fix punctures etc", was his brief response.

"Do you do these yourself or you have some one else with you".

I do have another boy, but I do all that he does...."

This is where the feat becomes remarkable. He can bring out a tube out of a bicycle tyre, fix it and put in place. And then fix the tyre back into the cycle!

What is the big deal? So can many of us?

The big deal is, his physical limitation is not restricted to his right eye alone. His right arm got dis-inserted from its root in the shoulder joint by the same accident that claimed his right eye!

Think again, can you do what he does?

Patch one of your eye, that would affect your ability to have a quality stereoptic vision.

Now ask some one to bandage and anchor your right arm over your chest so that it is completely immobile.

Pick up a screwdriver or any other tool. You are allowed to use your legs or knees to have a grip on the bicycle or its tyre. Remove the tube.

Can you?

I can't.

But my hero can!

So if you happen to live a restricted life due to disability, remember, someone somewhere is carrying on despite a problem more severe than yours!

Everyone would find a worse sufferer and a better conqueror than him.

So why have self pity that I termed a kind of masochistic feeling?

Carry on.

Be your own role model!

All the best, and excuse me for I can't unscrew even simpler gadgets!

Manish

Health insurance for senior citizens

A

Going through the details of any insurance policy can be a daunting and boring task for many. Scrutinizing a health insurance policy can be even more difficult since an average person is not expected to know the medical jargon. The issue is further complicated since the insurance companies add several “ifs and buts” to their policies.

Some of the clauses used by these companies include, “pre existing illnesses, critical illnesses, extra loading on the premium etc”. A complication arising from a pre existing illness may be treated entirely differently. Thus while the Oriental insurance company may claim that it would pay up to 50 percent of the sum assured in “chronic renal failure” which is a serious disorder of the kidney, at the time of actual reimbursement of the sum, the company may easily hide its head under the “exclusion criterion” if the renal disease is secondary to diabetes, which the company would like to push under a carpet termed as the “diabetic nephropathy”!

Most of the conditions that typically affect the old “geriatric” group of patients tend to be either excluded (examples include joint replacement due to degenerative disease, benign enlargement of prostate), excluded for initial specified period (e.g. cataract) or included at extra premium or with only a fraction of the sum assured payable!

This leads to an obvious dilemma: Should a senior citizen actually go for a health insurance? …. With the restrictions imposed? …At the premium suggested?

I think a senior citizen and even any citizen opting for health insurance needs to go for a medical consultation with a physician who would have detailed information about the personal and family history of a prospective insurance client. This is justified since even the insurance company gets assistance from medical fraternity in understanding the general “prognosis” and the likelihood of a complication before approving a policy.

Some general tips before taking the plunge:
Compare the age at entry, age up top which the policy can be extended, conditions excluded, critical illnesses included. These apply to everyone.

Then one can seek a case specific consultation: Reveal all the information to your physician guide, who can then assess if you are at increased risk for a complication or not. And if so, is it worth opting for a policy?

There are at least four five insurance companies in India that deal with senior citizen health insurance.

Best wishes,

Manish

Can be reached at xs2i@hotmail.com

Why did you go away....

I recall Rashmi as a playful, chubby baby of one & half years age brought to my clinic sometimes in December 2000. Accompanied by her parents & few “well wishers”, she certainly looked a very quiet & disciplined child for her age. The reason for consulting me was obvious: this little girl had an anomaly over her face. Her left eye was visibly smaller than the right one ever since her birth. In addition, she was a premature child.

Unaware about the implications of this facial asymmetry, the parents were primarily concerned with its cosmetic aspect. “After all…”, said one of the well wisher of the family, “she is a girl! Who would marry her, doc sa’ab”. I requested these “uncles” to leave the room so that I could have some quality time with the parents who needed to see the problem in correct perspective with fewer distractions.

“I must examine her under anaesthesia”, I explained after having discussed the need for a proper evaluation. The smaller of the two eyes could have a significant refractive error necessitating early introduction of glasses to ensure proper functional development of her retina. Not treated this way, there would be every chance of this eye becoming “lazy” or “amblyopic” as it is called in medical jargon. The child could eventually develop a squint.

As a premature baby, she was also prone to ROP (“the retinopathy of prematurity”) , although I felt it was unlikely in this particular child.

On the day of the examination, she happily allowed to be escorted to the operation theatre in a nurse’s lap. She drew her head up curiously as the anesthetist approached her with a small scalp vein set soon to be introduced in one of her veins. As the doctor pushed it in, the child looked in utter disbelief as if trying to say “You too, Brutus!”. Minutes later, she was fast asleep under the effect of the intravenous drug.

The examination was soon over & the child was in the recovery room. The parents were explained that the child would need another visit a few days later, a set of spectacles & there after, periodic check ups.

Out of no where, turned in a “well wisher”. Agitated they indeed were, since their hapless child had not been fed since early morning.

The well wisher was annoyed as the glasses were not prescribed immediately.
“We would better take her else where!” came the decree from the well wishing uncle.

I tried to pacify the parents in vain that we already have enough information about the child, but the uncle had struck!

That was the last time I saw Rashmi.

I don’t know which centre they took the child to. The child would have been through a repeat examination under anesthesia, with more punctures in her skin.

The moral of the story for Indian attendants is as follows:

(1) Let the doctor deal!

(2) Beware of the well wishers turning in at the very last moment. They would often like to have a prominent role in the management and would like to make up for their delayed entry in the scene.

Moral for Indian doctors:

(1) Try to communicate to the parents, take them in confidence in the very beginning.

(2) If there are too many well wishers, ask the parents to decide who would be there for discussion regarding the management.

Colour blindness.... Will it affect my driving and job prospects?

A senior ophthalmologist reading my blog, brought out the fact I had missed out writing on colour blindness.

I would use this opportunity to comment on that and also include information on job and educational prospects.

In India my clinical experience says that different "RTOs" apply arbitrary criterion for driving licenses: Be it a colour blind person, a simple myope or some one else. The lack of consistency may not be unique to India, European Union and the USA & Canada all have different guidelines applicable in different regions. (The difference being that, the laws are applied in a consistent manner!).

Bulgaria allows driving licenses to colour blinds, most countries in the EC do not. In the USA, some states have legislation that treats "a new or a professional" driver differently. Most states also have "restricted licenses" as well, allowing one to drive in specified conditions that include factors such scotopic or photopic (day light or otherwise) conditions.

In India, the pattern of governance and bureaucracy is far different from what one sees in more mature democracies. I don't intend to criticize "my country" since I am sure, better information, transparency and appropriate use of the right to information will address most of the unresolved issues over a period of time.

I recall, way back in 1985, fresh through a state Pre Medical Test, I was made to go through a "fitness test". Being a myopic, I expected to be asked to read the Snellen's chart to begin with. Instead Dr. Tandon, sipping tea leisurely, asked me to hand over my glasses to him. With one eye closed, the "veteran" looked through my concave glasses and instantly decided my fitness:

I was declared "not fit" to pursue medicine! No retinal evaluation, no best corrected visual acuity! No response to my pleading either!

How did I get across that hurdle is a different story. As an ophthalmologist, I continue to see such examples of human wisdom, where these "omniscient guardians" of Indian law decide some one's fate.

Most recent one was a guy who was not allowed to enter into "fisheries" at a renowned world class univeristy. As a colour blind, I wonder if he would have problems identifying the species of fishes! When last heard, he had moved court against the discrimination.

Access to education is a basic right. Reader may find the story of a medical student from All India Institute of Medical Sciences who was not allowed to take examinations following his visual loss due to Eales' disease until the NHRC came to his rescue. (See earlier post: "Success amidst adversities").

It is amazing, that in this era, where "equal opportunity employer" is a widely used tag, such things continue to happen! There are ways to tackle such issues - the legal ones. The right to information is an easier tool than moving the court! If you are not keen to go these ways, in India you tend to use "connections" or go and pay "bribe", the panacea for all!

The choice is yours.

Returning to the basic issue: Can colour blindness affect job prospects?

Using a disclaimer that this blog is not a comprehensive source of information, I would say, there are professions such as armed forces (specially aviation), railways, etc where an individual's ability to judge colours tends to be of paramount importance and being a colour blind would make him prone to errors.

There are however plenty of work places, I feel, where a blanket restriction is not needed. A student of fisheries may go on to study something that relates to the impact of toxic waste on aquatic ecosystem if not the morphology of colourful fishes! Would you not allow such a person to even study a subject of his choice? Same applies to the blind medical student from New Delhi, who still had a great potential to be a psychiatrist! But for that he needed to obtain his bachelor's degree first!

Simply underlining that a change is needed. Who can bring about those changes best? You, if you are the one facing obstacles!

Best wishes.

Manish

Visual requirements for driving in India and elsewhere

Few months have passed since an Indian immigrant in Canada walked into my clinic. He had been denied a driving license by the Canadian authorities.

"... The guy didn't cooperate!", he said, shrugging his shoulders and looking at me furiously, as if I was the one who denied him his driving license.

"... And he didn't cite any reason either!", he continued.

I examined him thoroughly, and realized he had a normal vision but was a "Primary Open angle Glaucoma Suspect".

I explained him, "See, you need to undergo a test called automated perimetry, that will help us decide if you have a normal field of vision or not. With a normal result, you get a license, without it driving may be hazardous, and in your own self interest, you may avoid driving".

I am not sure if he was indeed seen as a glaucoma suspect in Canada, but in all probabilities they seem to be carrying out a good evaluation.

I don't know what happened to the guy, but he called me this morning and asked me if I could e mail him his glasses' diopteric power. I complied with his request and mentioned his visual status on the specified date.

That was this Canadian chap!

Another girl came to me today and told me that the local office had refused a driving license to her brother. The report suggested a best corrected visual acuity of 6/12 in one eye and 6/6 in the other eye. The visual acuity of 6/12 did not match with my record of 6/9.

Apparently, the license authority had gone by his perception about myopia; the boy had moderate myopia but could read well with his glasses. No other evaluation was carried out.

So, this is a contrasting situation: Two countries, two norms. Worst, the Indian authority in the second case didn't seem to know the realistic guidelines for determining the eligibility for getting a driving license.

There are more differences in the Vision Requirements for Driving Safety in different countries:

In Canada, the visual field requirement in Quebec may be different from other provinces. While the visual acuity requirements in India is 6/18, Canada allows a license with a visual acuity of 20/50 (equal to 6/15 in Indian proportion). But unlike Canada, India doesn't have visual field restrictions! In some countries such as U.K., visual acuity is tested if the driver declares an eye disease. Venezuelan authorites resort to routine evaluation of visual field by "confrontation" method where a person with a normal field would compare his field grossly with that of the applicant.

The requirements in the USA differ from state to state and strangely, In Indiana and in Michigan a monocular patient could be allowed with a vision of 20/50 (0.4, 6/15) whereas the requirement for binocular drivers is 20/40 (0.5, 6/12). In the USA, bi optic telescopes are allowed in some states.

So if you are in India, you would need to educate yourself and then can appeal against any odds that you might face due to the ignorance of the "system", while if you happen to be an immigrant in a country that tests the visual field, understand that safety of you as well as others depends on more factors than mere driving skills .

I sincerely hope, that the Indian authorities would soon define a criterion for visual field as well.

Happy driving!