Cooking For The Dictators

When I read the premise of the Polish journalist Witold Szablowski's book "How to feed a dictator", I was immediately hooked. In this book he has interviewed the personal cooks of some of the more infamous dictators of 20th century, most of whom were also known mass-murderers.

I think that to have the deaths of hundreds of persons on your conscience and to live with that burden, you have to be some kind of psychopath. The history shows that often these persons also had charismatic personalities, as epitomized by Hitler and Stalin. These persons have their die-hard fans, who continue to be their followers even after listening to the stories of tortures and violence committed by their idols. Both, fascism and communism attract believers, similar to the attraction of radical religious ideas for certain persons. Believers and followers are necessary to make these persons what they finally become.

I was curious to know, how did their cooks, who have an opportunity to observe their bosses in their private and personal moments, saw those monsters? I finished the 200 pages-long book in 2 days. The insight it gave me is the extreme banality of becoming dictators - ideology can blind people and make them do all kind of things which facilitates dictatorship!

Some Personal Background

Let me start with a confession - lately I seem to have become very weak-hearted. I can't watch any scenes of gory violence or the horror films. I also can't read any books about violence. Earlier, I was not so weak-hearted, but over the past few years, I just can't bear the feelings of dread such films/books can create.

Thus, reading Szablowski's book was an unusual decision for me. I started reading it with the idea that if it had any graphic scenes of violence or torture, I would stop reading it. However, it does not go into the details of the deeds of those dictators. Most of the time, Szablowski only skims the surface, giving superficial accounts of the killings and the tortures.

During my travels around the world, I have been to many countries with communist regimes and some countries with dictators. Once, I even risked being taken prisoner by a group of communist guerrilla fighters. Listening to the stories of persons who had lived in these places, has cured me forever of the romantic ideas about revolutions and the charm of all kinds of ideologies such as communism and fascism.

I believe that violent struggle/revolution to fight against injustice and oppression is not a solution - it substitutes one kind of oppression and injustice with another kind, which is usually equally ferocious and implacable, and sometimes worse than what it replaces. Szablowsky's book has many stories about it.

Sometimes, I used to have long and animated debates with friends who believe in communism - I have learned to not argue with them. They are blinded by their beliefs and there is nothing I can say which can convince them otherwise. For example, I am sure that they can read Szablowski's book and find justifications for everything.

Dictators in Szablowski's Book

In his book Szablowski presents the stories of the cooks of 5 dictators - Saddam Hussein (Iraq), Idi Amin (Uganda), Enver Hoxha (Albania), Fidel Castro (Cuba) and Pol Pot (Cambodia).

I already knew many things about all of them except for Enver Hoxha, the communist dictator of Albania. To read about him was a revelation. All the 5 protagonists of this book were paranoid personalities or perhaps, it would be better to say that once you become a ruthless dictator and are forced to kill people or to get them killed, you have no option but to become paranoid.

All the cooks of this book are men, except for the cook of Pol Pot. All of them, were associated with their bosses from their early carriers, before they had become the famous dictators. All were forced to become cooks because their bosses were suspicious of others and wanted someone they knew for this role. All of them walked on a tightrope, aware that their boss may suddenly feel that they are not faithful and decide to get them killed. Any dish cooked with too little or too much salt could have been seen as an attempt to poison.

The cooks' stories bring out the insecure men hiding behind the persona of ferocious dictator for whom they were working. Their stories bring out the specific personal traits of each of them, like Fidel Castro, who thought that he knew everything and gave long and boring lectures to everyone about how to do something, including to his cook. These parts of their stories give a comic touch to the book, even while in the background, the purges continue and the people surrounding the dictators fall out of favour and disappear.

The most fearsome person in the book is Pol Pot, also known as Brother Pouk or Brother Mattress or Angkar. He is fearsome because he is very handsome (according to his cook who sounds in love with him), always gentle and smiling. He is surprising because he is kind to his obviously mentally ill wife. He is fearsome because he believes completely in the teachings of Marx and Mao, and is willing to go to any length to realise his communist paradise - including killings of professors, doctors, writers and all the persons who have an education, and relocation of millions of city inhabitants to countryside so that they may learn the virtues of manual work and hunger. He is also most fearsome because he evokes obedience even from persons he has ordered to be killed. Even his cook who knows that she can never betray him, says that she would have been happy to be killed because "If Angkar has taken a decision, then he must be right".

I have never been to Cambodia, but I had heard many similar stories during my journeys in China and Vietnam in late 1980s and early 1990s.

Away from the cameras and the journalists, in their private lives, these mighty dictators were just little guys, missing the cooking of their mothers and their home towns, getting drunk, sometimes petty and sometimes generous, finding a refuge in their ideologies.

Conclusions

Sbzablowski's book does not make any new revelations but it gives a different point of view of seeing the infamous dictators of 20th century - persons who had made history and influenced their worlds. I felt sympathy for those cooks, who now try to hide behind ordinary lives, so that no one comes to look for them and to hold them responsible for those events, which took place when they were close to the powerful.

Some of them, who had met kings, queens and prime-ministers and had cooked for them, travelled around the world in private jets and Mercedes cars, are now living lives of poverty, usually ignored by most regarding their illustrious past.

I think that it is good book to read if you are interested in history and in humanity - it shows you how chance and destiny can shape a life and how power corrupts. It also shows that nothing lasts for ever and sooner or later, one day even the most powerful dictator would have to concede defeat.

*****

#bookreview #books #bibliophile #historybook #dictators

Searching for Dragon Bones

Recently our Book-Reading Group in Schio (Italy) decided to read Tracy Chevalier's book "Remarkable Creatures". It is the story of 2 women in early 19th century England and their love for fossils and old bones.

Reading this book reminded me of a visit to a museum in Bologna some years ago, as well as, of discussions about dinosaur bones in the Gobi desert in Mongolia. Friends had told me that in Mongolia and China, people used to believe that the dinosaur bones were dragon-bones, and were used as medicines by traditional healers.

This post is about Tracy Chevalier's book, as well as about discovery of fossils in medieval Bologna. It is a kind of a rambling post about how scientific discoveries are inter-connected and can change the way we see the world around us. Let me start with Chevalier's book.

Remarkable Creatures

Chevalier is a British author of American origins who writes historical novels. She became famous with her book "The girl with the pearl earring" in 1999 while "Remarkable Creatures" came out in 2009.

The book is set in the coastal town of Lyme Regis in south England. The tiny town of Lyme has been the backdrop of many books, including "Persuasion" by Jane Austen and "French Lieutenant's Woman" by John Fowles. It is a fiction-book based on real persons, who lived there in the 19th century. On her website, Chevalier provides the following background to her decision to write this book:

A few years ago I went with my son to a small dinosaur museum in Dorchester, on the south coast of England. Among the usual displays, there was a wall devoted to Mary Anning, who lived in the early 19th century in the nearby town of Lyme Regis, where fossils are abundant. The display showed a sketch of Mary on the beach, holding a hammer and wearing a top hat to protect her from falling rocks. At age 12 she discovered the first complete specimen of an ichthyosaur, a marine reptile about 200 million years old

The book starts with the friendship between the two women - the 12 years old Mary Anning from a working class family and a resigned-to-spinsterhood, Elisabeth Philpot. Mary searches for the fossils on the coast to sell them to the tourists. Elisabeth has been sent to live in Lyme, as her brother has decided to get married and his wife does not wish to share the house with his sisters. In Lyme, Elisabeth discovers her love for the fossils and old bones, and in the process, recognises the genius of Mary in finding them.

A dinosaur skeleton, now displayed in the Natural History museum in London, discovered by Mary Anning, plays a key role in the story. I love that museum and have been there a few times (2 of the images used in this post are from that museum). However, before reading this book, I had no idea about Mary Anning and the role she had played in discoveries of the dinosaur skeletons in England.

Book's Themes

The story is set in the early 19th century England, a period when class distinctions were still strong and the society did not accept friendships between persons of different classes. It was also a period when women were much lower in the hierarchy compared to the men - they did not have any independent rights and were dependent upon the men of their families for all decisions. It was a period when religious orthodoxy dominated and was hard to challenge.

It was a period of transition, where the finding of fossils was problematic as it raised issues for which the answers inevitably led to a questioning of religious dogmas. The Bible said that God had made the creation over a period of 6 days and all creatures made by God were perfect. The fossils and dinosaurs did not fit into this narrative because they implied that some creatures had existed in the past and had become extinct. The church negated these suppositions which did not fit the theory of creationism.

In that period, only men were supposed to be discoverers and scientists while women like Mary or Elisabeth were not supposed to be one. Thus, men interested in the fossils and old bones of giant animals (the word dinosaur had not yet been coined), took the knowledge and specimens from Mary and showed them off as their own finds. The book concludes as the first fissures apear in this male-dominated construction of the scientific world and Mary becomes known as the person who understands fossils much better than anyone else.

It is a gentle book, focusing on the social milieu as well as, on the inner lives of its female protagonists, and is very easy to read. There are parts of the story, like the man who had duped Mary suddenly discovers his noble side, which are a little unconvincing but overall the book is informative and enjoyable. Even Jane Austen makes a fleeting appearance in the story. For me, the most interesting parts of this book are those where the process of finding the fossils and the beginning of slow understanding about their origins are described.

Aldrovandi & Geology

Reading about fossils reminded me of a naturalist from medieval Bologna in Italy. In a recent article by Lawrence Wright in the New Yorker, Bologna is described as "the giant churches, the red-tiled roofs, the marble walkways under arched porticoes; a stately city, low-slung, amber hued, full of students and indomitable old couples. During the Middle Ages, Bologna was home to more than a hundred towers, the skyscrapers of their era, which served as show-places of wealth and ambition for powerful oligarchs. Two of the remaining ones have become symbols of Bologna: one slightly out of plumb, the other as cockeyed as its cousin in Pisa."

This article touches on the social transformations brought about by the pandemic of black death (plague) in the 14th century and proposes that the pandemic had led to the period of Italian Renaissance and to a new way of understanding the world. It asks what kind of the transformations will be stimulated by the present Covid-19 pandemic and in which ways those will shape our future world.

One of the key figures of 16th century Bologna who had contributed to the scientific transformation of Renaissance was the naturalist Ulisse Aldrovandi. He was born in Bologna in 1522. Leonardo da Vinci had died a couple of years earlier while Michelangelo had yet to start painting the Sistine chapel. Thus, we were in the middle of Italian Renaissance period. It was also the time when the Spanish inquisition had already started and it was easy to be accused of being a heretic. In fact, Aldrovandi himself was imprisoned for about a year and a couple of decades after his death, in 1633 Galileo was sentenced to life-imprisonment for suggesting that the earth was not the centre of the universe and it revolved around the sun.

Aldrovandi had suggested that nature had to be looked at as "juxta propria principia", that is without religious or metaphysical conditioning. Among the objects collected by Aldrovandi were some seashells found in the mountain expeditions. This raised questions in his mind about how those sea creatures had reached the mountains? The Biblical justification to these findings was in the story of universal floods and Noah's ark. These made him think critically about the study of different layers of earth and how it was composed of different kinds of rocks and minerals. In his testament written in 1604, he used the word "geology" for the first time to indicate "the study of earth".

Some diaries of Leonardo da Vinci have also been found, where he had written about the finding of seashells and fish-fossils in the mountains. One of his hypothesis was that at some point in the earth's history, the mountains had been at the bottom of some sea. Thus, while Bible imposed certain beliefs regarding the creation of the world, and inquisition awaited persons who questioned those beliefs, persons already had other ideas, which contradicted Bible's idea of creationism.

Poggi museum of Bologna holds the Aldrovandi collection and includes the collection of "Diluvianum Museum" created in early 1700 by another local naturalist, Giuseppe Monti. It presented the fossils as part of the objects created by the Biblical floods (Diluvianum). The wall paintings of this room show those floods as imagined by the artists (an example in the image below).

Thus, it was not only Mary Anning and Elisabeth Philpot, but countless others including Androvandi and Monti, who had started to explore the world with new eyes and to question it, which had created the foundations which had led to Darwin's theory of evolution and forced the church to change its position on creationism. In "Strange Creatures", Elisabeth tentatively proposes that the "6 days of creation" of the Bible could have been 6 eras of creation.

Conclusions

Often, specific scientific ideas are associated with names of specific persons. For example, the theory of evolution is linked with the name of Charles Darwin. However, as this post shows, scientific advances do not come out of a vacuum, basic knowledge which contributes to them is the work of countless others who are not remembered by the history books.

So much of history and society is taken for granted. Like the discoveries of fossils, dinosaurs and the Darwin's theory of evolution - we accept all of these almost uncritically.

Art and literature can play an important role by reminding us how and in which conditions those discoveries took place and their human costs. That understanding helps us to look at the past in a more realistic way, so that we can understand better where we have reached and where we are going.

*****

#dinosaurs #tracychevalier #bookreview #remarkable_creatures

From Butchers to Surgeons

Recently I read Dr. Lindsey Fitzharris' 2017 book called "The Butchering Art". It is not a book for the faint-hearted. In this book, she describes the way surgery was done in England till late 19th century and how two discoveries - anaesthesia and antisepsis, revolutionised it. Before those discoveries, surgery was the domain of butchers.

Reading this book raised a question in my mind about surgery in ancient India. More than two thousand years ago, ancient Ayurvedic surgeons were doing different surgeries including full-thickness skin grafts and plastic surgery operations such as rhinoplasty. I have already written a blog post about it. The question in my mind was, how did ancient Indian surgeons resolve the problems of anaesthesia and prevention of bacterial infections during their surgery?

This post is about the Fitzharris' book, as well as, about ideas of anaesthesia and asepsis from the ancient Indian text of Sushrut Samhita.

The Butchering Art

Fitzharris has a vivid way of writing. She brings alive the old and forgotten world of surgery, before the discovery of anaesthesia. Her writing is so graphic, that at times it made me feel a bit queasy. Her book starts on a December day of 1846 and describes one of the first surgeries done under the effect of Ether anaesthesia at the London University College hospital. The surgeon was Robert Liston and on that day, as usual the operation room was full of spectators, who had paid a ticket to watch the show.

It was a time when surgery was reserved for desperate and life-saving situations. Surgeons operated on conscious persons, who had to be held on their place by a group of strongmen. The lucky ones lost consciousness and were thus spared the pain of their bodies being opened and their bones being sawed off. The most important quality of surgeons was their speed in finishing the operation.

In the middle of the room was a wooden table stained with the telltale signs of past butcheries. Underneath it, the floor was strewn with sawdust to soak up the blood that would shortly issue from the severed limb. On most days, the screams of those struggling under the knife mingled discordantly with everyday noises drifting in from the street below: children laughing, people chatting, carriages rumbling by. ...At six feet two, Liston was eight inches taller than the average British male. He had built his reputation on brute force and speed at a time when both were crucial to the survival of the patient. Those who came to witness an operation might miss it if they looked away even for a moment. It was said of Liston by his colleagues that when he amputated, “the gleam of his knife was followed so instantaneously by the sound of sawing as to make the two actions appear almost simultaneous.” His left arm was reportedly so strong that he could use it as a tourniquet, while he wielded the knife in his right hand. This was a feat that required immense strength and dexterity, given that patients often struggled against the fear and agony of the surgeon’s assault. Liston could remove a leg in less than thirty seconds, and in order to keep both hands free, he often clasped the bloody knife between his teeth while working.

It was also the time when people had no understanding about bacteria and infections. If the patients did not get the infection from the dirty hands, blood-soaked aprons and instruments of the surgeons working in crowded halls where people were sneezing, coughing and talking, they got it from others who were admitted in the crowded hospitals. Mortality due to post-operative infections was very high.

In the 1840s, operative surgery was a filthy business fraught with hidden dangers. It was to be avoided at all costs. Due to the risks, many surgeons refused to operate altogether, choosing instead to limit their scope to the treatment of external ailments like skin conditions and superficial wounds. ... The surgeon, wearing a blood-encrusted apron, rarely washed his hands or his instruments and carried with him into the theatre the unmistakable smell of rotting flesh, which those in the profession cheerfully referred to as “good old hospital stink.” ...At a time when surgeons believed pus was a natural part of the healing process rather than a sinister sign of sepsis, most deaths were due to postoperative infections. Operating theatres were gateways to death. It was safer to have an operation at home than in a hospital, where mortality rates were three to five times higher than they were in domestic settings.

The book starts with discovery of anaesthesia and then quickly moves to its main subject - the ideas of antisepsis and their impact. It tells the story of Joseph Lister and his ideas about prevention of infections during surgery. During 1850s, Louis Pasteur in Paris had come up with the theory of invisible germs which were responsible for souring milk and fermenting grape-juice for making wine. In 1862 he boiled milk, which prevented souring of milk and proved his theory. Lister, who was passionate about microscopes, heard about Pasteur's work and felt that similar microscopic germs were responsible for causing infections in patients during surgery. In 1865 he developed his antiseptic solution based on carbolic acid, and showed that it was possible to reduce the post-operative mortality due to infections.

The book starts with discovery of anaesthesia and then quickly moves to its main subject - the ideas  of antisepsis and their impact. It tells the story of Joseph Lister and his ideas about prevention of infections during surgery. During 1850s, Louis Pasteur in Paris had come up with the theory of invisible germs which were responsible for souring milk and fermenting grape-juice for making wine. In 1862 he boiled milk, which prevented souring of milk and proved his theory. Lister, who was passionate about microscopes, heard about Pasteur's work and felt that similar microscopic germs were responsible for causing infections in patients during surgery. In 1865 he developed his antiseptic solution based on carbolic acid, and showed that it was possible to reduce the post-operative mortality due to infections.

The book is a fascinating read. Even if Lister proved the importance of antisepsis in preventing infections, for a long time, surgeons were sceptical about his ideas. Lister was helped by others who helped in spreading his ideas. He had inspired the maker of Listerine , which is now known as a mouth-wash but was initially developed as a disinfectant in operation theatres and used for cleaning wounds. He had also inspired Robert Wood Johnson , who had started Johnson & Johnson company to make sterilised dressings and sutures. It was not until 1877, when Armour Hansen saw the leprosy bacillus under a microscope, identified it as the cause of leprosy and firmly established the germs theory of infections.

Surgery in Ancient India

Sushruta is considered as the father of shalya-chikitsa (surgery) in Ayurveda. Various modern text books on surgery and plastic- surgery acknowledge that some of the techniques described in his treatise "Sushruta Samhita", such as that of full-thickness skin graft and rhinoplasty, have inspired them and are still used. When I read the Fitzharris' book, I wondered how did the ancient Indians develop those surgical skills without modern anaesthesia and antisepsis? To make a full-thickness skin graft or to do rhinoplasty, the surgeons need patients who are calm and can lie still for some time. It was not a work that a person with brute force could do by cutting away a part of the body while others held the patient. Such delicate surgeries would have been wasted if there were post-operative infections. So how did ancient Indian surgeons such as Sushruta do those surgeries?

I searched on internet and found an English translation of the first volume of Sushruta Samhita - it was translated from Sanskrit by an Ayurvedic doctor called Kaviraj Kunjalal Bhishagratna in 1907. In the introduction to the volume, he explained that this was not the original text of Samhita written by Sushruta, rather it was a commented version written by a person called Nagarjuna and was probably written around 3rd or 4th century BCE.

I found some answers regarding the questions of anaesthesia and use of anti-sepsis in surgery in the introduction of this text:

Verses about medicine, hygiene and surgery lie scattered through out the four Vedas. ... There were 5 groups [of healers] - Rogaharas (physicians), Shalyaharas (surgeons), Vishaharas (poison curers), Krityaharas (demon doctors) and Bhisag-Atharvans (magic doctors). (p. 13)[Sushruta] first classified all surgical operations into different kinds ... Aharya (extraction of solid bodies), Bhedya (excising), Chhedya (incising), Eshya (probing), Sivya (suturing), Vedhya (punturing), and Visravanya (evacuating liquids). ... Sushruta enjoins the sick room to be fumigated with the vapours of white mustard, bdellium, nimva leaves and resinous gums of Shala trees, which foreshadows the antiseptic (bacilli) theory of modern times. (p. 16)Amputations were freely made and medicated wines were given to patients as anaesthetics. ... In those old days, perhaps there were no hospitals to huddle patients together in the same room and thereby to create artificially septicemic poisons which are now so common and so fatal in the lying-in rooms. A newly built lying-in room in an open space filled with the rays of the sun and the heat of burning fire, and for each individual case the recommendation of a fresh bamboo chip for the section of the [umblical] cord are suggestions the value of which, the west has yet to learn from the east. (p. 19-20)

This brief description shows that in many ways, Ayurvedic surgeons had found solutions to the problems of sepsis and anaesthesia, which had plagued the surgeons in the UK till 19th century. Use of fumigation, sun light, keeping persons separated, using a new and clean cutting instrument, are all ideas that are known to promote antisepsis. Use of medicated wines for anaesthesia needs to be understood better to see which kind of medications were used. My knowledge of Sanskrit is limited but probably there would be more detailed information in the texts of Sushruta Samhita, which can give us more precise answers.

Those understandings of ancient healers like Sushruta were probably based on centuries of observations and experiments, though they had no real understanding of different kinds of bacteria and infectious agents as there were no microscopes to directly observe the micro-organisms. As the quote about different kinds of healers shows, the world of ancient healers was also a world of magic and demons, and thus it is likely that many of the old ideas would be expressed in "unscientific" terms.

Challenges of Understanding Ancient Wisdom

I think that at least some of such ancient understandings were common heritage of humanity and not just limited to India. In large parts of the world such ancient knowledge has been lost because many of the old traditions, along with old gods and their myths were discarded, before they could be codified, written down and preserved for posterity. It is easy to discredit ancient experiential knowledge because it is expressed in unscientific terms and is associated with old myths and ideas of supernatural. In India, in spite of invasions and mixing of cultures, fortunately there has been a civilisational continuity and thus the traditional knowledge in the old texts has been kept alive, and even today Ayurveda is a living tradition, followed by millions of persons.

Unfortunately, there is a tendency in India to diminish the importance of Ayurveda and its knowledge, as explained so eloquently in a recent article by Madhulika Banerjee, where she has written:

... my research has shown me several other worlds of Ayurveda — the world of the practising Ayurvedic doctor, the teachers in the scores of colleges and universities of Ayurveda and researchers in different institutes. These worlds are much bigger and deeper, beyond that of Patanjali, Dabur and Himalaya. That world is vibrant, has integrity and it is important that it be known, respected and valued. ... Under the influence of colonialism, we tethered the language, the institutions and the systems of Ayurvedic knowledge production to the margins of our learning and education. We closed many doors and windows of scientific practices within and around traditional medical systems. But in a trick of inversion, we say they do not follow the language and methodology of science.Despite Ayurvedic knowledge being rooted in a different philosophy, teachers have found ways of keeping up the process of adapting learning from the texts to contemporary education, fitting into modern classifications of anatomy, physiology and higher specialisations at a deeper level. They have both adapted to and adopted new knowledge, widening their horizons unhesitatingly, true to their tradition. Yet they have to face unhappy students, struggling with low self-esteem, under immense pressure to compromise their knowledge.... When two knowledge traditions have two completely different perspectives on body and disease, then why compete on the medicine and cure? And when parameters of treatment and expected outcomes are of different kinds, then how can the protocols of biomedicine be used for evaluating Ayurvedic medicines? Why can Ayurvedic manufacturing not focus on creating a different world of diagnosis, treatment and cure in keeping with its perspective, expanding the range of choices patients have?
I feel that the last part of Banerjee's quote above is fundamental - the value of the knowledge in Ayurveda can not be and should not be limited to evaluations by "scientists", it also needs to be understood and judged according to its own perspectives. For example, words like dosha, pitta, kapha and vayu, which are fundamental to ideas of Ayurveda, represent complex ideas that can not be translated into illness, bile, mucous and air and then laughed at, because they do not fit our understandings as modern doctors.

As explained in my blog-post on Ganesha story and ancient Ayurvedic techniques of plastic surgery operations on the nose (rhinoplasty), these were copied by British surgeons from India fairly recently (during the last part of 18th century). Yet, that does not stop "modern" doctors from calling Ayurveda as "alternative" medicine or worse, implying that these are inferior knowledge systems, if not outright quackery.

Conclusions

Linda Fitzharris' book on the old surgical art of butchering provides a glimpse into that time when getting a tooth extraction or having an abscess incised could lead to sepsis and death. It was also a time of unimaginable pain as persons were immobilised while the surgeons amputated their limbs or did similar operations. Discovery of anaesthetics and an understanding of spread of infections has led to the world today, where we have advances like laproscopic surgery, laser surgery and robots which can do delicate operations.

Forty years ago, when I had studied medicine, I had learned how to use ether anaesthesia for work in rural hospitals which did not have access to a Boyle's machine for anaesthesia. It was still the same technology which Fitzharris has described in her book as taking place in 1846. I don't know if anywhere anyone still uses that primitive approach to anaesthesia! So in way, I could directly identify with that world and feel the horrors of having brutal surgeries without anaesthesia.

It was also enlightening to read the book about Sushruta's techniques of surgery more than 2,500 years ago and appreciate how he and other ancient healers in India had developed an understanding about both anaesthesia and asepsis and were able to conduct and develop complex surgical techniques and to find that some of these techniques were copied in the west fairly recently (in 18th century).

I don't think that Ayurveda and ancient texts like Sushruta Samhita would all make sense according to the modern scientific understandings. They are texts of their times and they would have their parts of myths, stories and fantasies, interspersed with real experiential knowledge. As my brief exposition above shows, they did develop understandings which the modern medicine has developed only relatively recently. They do merit respectful analysis, even when we can't understand their meanings.

End-Note: The images used with this post are from the old anatomy theatre of Bologna in Italy and from an Ayurvedic college in Kerala, India.

*****

#bookreview #surgery #historyofsurgery #ayurvedicsurgery #ayurveda #lindseyfitzharris

A Liberian Story of Dung Beetles

The moment I read the title of the book "The Dung Beetles of Liberia", I knew that I wanted to read it. My links with Liberia go back to almost 25 years though I visited it for the first time only in 2018.

When I visit any country, I like to know its people and to understand their history and culture. However, though I have been to Liberia a few times, I have found it difficult to find a connection to the country's spirit, and in understanding its culture and history. Thus, the title of the book "The Dung Beetles of Liberia" immediately attracted me.

Dung Beetles

Dung beetles are found in the savanna regions in different countries of Africa and are not specific to Liberia. In my visits to Liberia, I have yet to come across these insects.

The tropical grasslands of Africa known as "Savanna" play a crucial role in ensuring the continent's bio-diversity. They are characterised by tall grass with a few scattered trees. According to National Geographic, the African savanna is the site of complex and inter-linked life-cycles:

"Healthy, well-balanced ecosystems are made up of multiple, interacting food chains, called food webs. Carnivores (lions, hyenas, leopards) feed on herbivores (impalas, warthogs, cattle) that consume producers (grasses, plant matter). Scavengers (hyenas, vultures) and decomposers/detritivores (bacteria, fungi, termites) break down organic matter, making it available to producers and completing the food cycle (web). Humans are part of the savanna community and often compete with other organisms for food and space."
According to Dr Frank Krell of the Natural History Museum in London, there are different varieties of dung beetles in Africa which play a fundamental role in ensuring the sustainability and survival of savanna by spreading the dung on the ground and by depositing it underneath hard soil so that it serves as fertiliser and nutrient for the savanna grass:

Dung is more than just waste, explains Krell; it is often full of seeds and burial by dung beetles may be crucial in the germination success of several plant species found on the savannah. Tunnelling and rolling species together not only distribute nutrients over the surface of the savannah but also dig it in for good measure, providing fertiliser at all levels of the soil profile to ensure a lush growth of vegetation during the rains. Around one tonne of nutrient-rich dung is deposited per hectare of the savannah each year, so there is more than enough to go round, especially once dug in by the enterprising insects.

Thus, though the dung beetles may be vital for the African biosphere, they are seen as dirty and the word "dung beetle" is used to denigrate. Therefore, it is important to specify that dung beetles are not "Liberian", they are present in different parts of Africa. In Meier's book, we are introduced to them in the first chapter, when Ken, a young American pilot flying an Africa Air Service (AAS) plane, has to make an emergency landing in a field near a nuns' mission because he has diarrhoea. Hidden from the nuns among the tall grass, he is busy shitting when he finds the dung beetles trying to crawl on his legs.

"Leaving the engine idling with the prop turning over slowly, I bailed out of the cabin. I ran to the bush, which was mostly grass and weeds about chest high, and, with only moments to spare, relieved myself. While this relief was occurring, I heard the distinctive wuush, wuush, wuush of dung beetles crawling through the grass. I had been told that they could hear a mouse break wind from five miles away and could follow the scent. With my pants around my ankles and the sun beating down on my head, I started a little hippy hop, hippy hop movement to keep away from them."
Apart from the first chapter, the dung beetles do not make further appearances in the book, at least not in the insect form. The dung beetles in the title of the book, make one think that it is an entomology book. When I started reading it, I thought that it was a light-hearted story of an expatriate in Africa and his struggles with local fauna and flora. Instead, the book refers to his encounters with other kinds of dung beetles, many of whom are also expatriates.

Other Dung Beetles in Liberia

Some dung beetles eat the shit, others live in it. Meier's Liberia is about 7 years in the life of Ken Verrier starting from 1961, while he is trying to escape from his guilt at his brother's death. The country seems to be full of bipedal kind of dung beetles - from a corrupt system oiled by "dash" and ex-slave Americo-Liberians living in the replicas of American plantation houses where they were slaves; from the Nazi pilots refugees from Germany on their way to South America to the Israeli spies. As the next excerpt shows, it seems that in the 1960s, Liberia was one of the richest economies in Africa and had different groups of expats.

A lot of wealth was pouring into the country, mostly from international corporations. The national transportation system was still largely underdeveloped. Most of the roads had been built by international mining, timber, and rubber companies. These roads served the companies as well as the people of Liberia and were not paved. During the wet season they often became impassable. There was one national airline, Liberian National Airways, but it flew only to a few nearby destinations outside of Liberia.

I was surprised to read about the Nazi pilots hiding in Liberia, I had never heard of it before. The description of their adoration for Hitler's ideology, makes for a disgusting and yet fascinating reading, in some ways reminding me of the Tarantino film "Inglorius Bastards". For example, check the description below of an evening at a place called Heinz & Maria in Monrovia:

I noticed that the volume of voices had gotten much louder. Beer was flowing more freely and the pilots started singing old beer hall songs, then Luftwaffe fight songs. One of the pilots stood up, swayed several times, took a couple of gulps of beer, and started singing the German national anthem. Everyone joined in, including Ana. When that was finished a pilot, whose name was Willy, climbed onto the bar, rolled up his right shirt sleeve to reveal a tattoo of a red swastika on his upper arm with “Deutschland Für Immer” inscribed beneath it. He started goose-stepping up and down the bar giving the Nazi stiff-arm salute and shouting, “Leben sie Langa, Liebe sie Langa, Fur Gott, Fuehrer und Vaterland, Machen Deutchland Wieder Groß!”The pilots cheered and toasted Willy with mugs of beer and then began a rhythmic pounding of their feet on the floor while shouting, “Ein Reich! Ein volk! Ein Füehrer! Deutschland für immer! Ja, ja!”

Liberia Today

Meier's book is about Liberia and Africa of 1960s and it looks at the country from a white American expatriate's eyes. Apart from the Germans and persons from international corporations involved in diamond mines, it touches on two other groups of expatriates - missionaries and Lebanese businessmen.

The Liberia that I have known over the past couple of years is very different and yet similar to the one described in the book. It has been devastated by decades of an incredibly brutal and prolonged civil war, followed by the deadly Ebola epidemic. During my visits in the areas affected by the civil war, I have heard nightmarish stories of violence by persons who were children at that time and saw their families raped and hacked to death in front of them. I have also talked to some who were forced to become child soldiers and who still carry the scars of their experiences on their souls.

I have heard that after the end of the civil war in 2003, for a decade Liberia was full of European NGOs and U.N. forces who had come here following the scent of reconstruction money and emergency aid programmes. They are all mostly gone now after the Ebola scare in 2014, when the GDP growth had plunged from more than 8% to less than zero. Though the Ebola epidemic was controlled in 2016, its shadow still seems to dog the country. The corruption mentioned in Meier's book still seems omnipresent while the violence seems to be hidden just below the surface of ordinary daily life, threatening to erupt now and then in the protests and witch-hunts, just like it does in the book during the part about President Tubman:

Tubman decided to make an example of them, so he announced there would be a Justice Day. And when that day came, justice was to be held in the football stadium. It was done at night for full effect. You know, like the Nazis used to do at Nuremburg with their torches and vertical lights. Herr Speer called it the ice palace.“It was like a sports affair. Vendors were selling cotton candy, beer, shit like that. And just at the right moment, he got up into the speaker’s stand and called for the criminals to be brought out. The same white Mercedes was driven out onto center field and two policemen got out. They opened the rear door and dragged out three guys who were handcuffed and chained together. Then Tubman made this long speech in the style of der Fuehrer about how he was going to put an end to crime and, after a timed pause, he extended both arms and said, ‘Now let justice be done,’ and the crowd went wild.”The cops dragged the three guys around to the rear of the car, opened the trunk and threw them in, and slammed the trunk lid down. A pickup truck drove out to the scene and the cops started offloading five-gallon cans of petrol. They must have dumped fifty gallons of the stuff in and on the car. Tubman gave the signal by suddenly lowering his arms, and the cops lit the car off. At that point the crowd let out a scream that made what’s left of my hair stand on end. I’ve never heard anything like it. It was like ten thousand people at the height of supreme ecstasy.

The book ends with a cliché image of Africa, a Guinea worm - Ken takes out a male worm from his knee, wrapping it around a match-stick and he realises that the demons chasing his soul are gone and it is time for him to go back to his home in the USA.

Looking for the Real Liberia

While visiting Liberia, I have felt as if I am visiting a country without a history. Which may be true in a way because it was created in 17th century by the freed slaves coming back from America. Their cultures and histories had been snatched away from them when they or their fathers had been captured and taken away in the slave-ships. They were brought back and had been implanted in the midst of local tribes. They had become the Americo-Liberians, subjugating the local tribes exactly as they themselves had been subjugated.

Given this history as the seed of their nation, it is no wonder that Liberians had to struggle to find a unity in their nationhood. It is quite likely that the process of assimilation is not yet complete and continues to erupt every now and then, in the lack of trust between its people.

Over the past five hundred years, the empire-builders and exploiters from north Africa and Europe have crushed and cancelled any sense of value the different African people had regarding their own cultures and beliefs. Religious proselytisation by Islamic and Christian preachers have brought new cultural values to replace the old beliefs. Except may be for Yoruba people in Nigeria, none of the civilisational cultures of Africa have survived this onslaught. Compared to the rest of Africa, the cultural challenges which Liberia faced were probably even worse and thus their transition to the modern nation state has had its ups and downs.

Conclusions

Today's Liberia is changing. There are no longer any big groups of German expats here. The Lebanese are still there but over the past couple of years, many of them have left the country. Instead there are groups of Indians, Chinese, Ghanaians and Nigerians who dominate the country's commerce. Thanks to the Chinese, there is a nice road from Monrovia to Ganta, though travel to rest of the country continues to be back-breakingly difficult, especially in the rainy season.

For me Meier's book was an opportunity to take a look at Liberia's recent history. I enjoyed it but in the end I feel that it is only a very superficial glimpse and has left me craving for more. I wish a writer like James Michner could have written a book about Liberia (like his books on Alaska, Hawa'i and Caribbean)!

Probably most African nations would also need such writers, who can combine the mythical with historical and civilizational ethos and with an ambitious vision to unearth their people's histories. Probably Nigerians and Ghanians have had more success in this, but I may be biased in the favour of anglophone world while similar voices exist in other areas of the continent,about which I am not aware.

*****

Influence of Parasites on Behaviour

Sometimes we think that we have understood something, then scientists comes up with new insights, which force us to rethink about that understanding. For example, over the past decade, insights about the gut bacteria which constitute our microbiome and might shape different aspects of our lives, from obesity to depression, have opened a new areas of scientific enquiry. The discovery of a "new body organ", the interstitial space, is another emerging area of research and understanding, which might have surprises waiting for us. Kathleen McAuliffe's book about parasites and how they might affect human behaviour relates partly to the role of gut bacteria, but has a wider scope. It did manage to force me to reflect about issues that I had not thought before.

About 50 years ago, when I had joined medical college in India, I used to think that almost all the things that could have have been discovered about human body and diseases had already been discovered. I imagined that technology might help us improve some things, like diagnosing some difficult to diagnose conditions, but I had no idea that in these 50 years scientific knowledge about some aspects of human body, such as genetics, was going to change so drastically. That is why I love reading books which give an understanding about human body and its influence on the changing practice of medicine.

McAuliff's book has a strange title, "This is Your Brain On Parasites", which does not sound very interesting, but its subtitle explains it better - "How tiny creatures manipulate our behaviour and shape society". This post is about this book, which I would divide into 2 parts - the first part is about different parasites which infest worms and insects and, change their behaviour; the second part is about humans. The latter is more speculative, it wonders how parasites and fear of illness might be influencing our sense of disgust and our behaviour towards "outsiders".

Parasites in Other Life Forms

In the first part of the book, McAuliff talks about researchers who have spent all their lives following the life cycle of a parasite and the surprising things they have discovered. McAuliff explains that searching for these stories was what led her to writing this book:The impetus for this book was a discovery on the Internet. I’m a science journalist and one day while foraging for interesting topics to write about I stumbled across information about a single-celled parasite that targets the brains of rats. By tinkering with the rodent’s neural circuits—exactly how is still a matter of fervid study — the invader transforms the animal’s deep innate fear of cats into an attraction, thus luring it straight into the jaws of its chief predator. This is a felicitous outcome not only for the cat but also, I was stunned to learn, for the parasite. It turns out the feline gut is exactly where the organism needs to be to complete the next stage of its reproductive cycle ... As I continued reading, more surprising news greeted me: The microscopic organism is a common inhabitant of the human brain because cats can transmit it to us when we come in contact with their feces. Perhaps the parasite was meddling with our brains too, speculated a Stanford neuroscientist associated with the research.
The stories of parasites entering the bodies of their hosts and changing their behaviour to suit their own desires, are like the stories of ghouls and spirits taking over and turning living beings into zombies - fascinating and frightening. At the same time, this part of the book explains the different obstacles these scientists had to overcome in their single-minded passion about one worm or one insect, over periods lasting decades. It is a pity that most of their names remain in obscurity.

For example, there is the story of the scientist Janice Moore who got interested in the life-cycle of a tapeworm and studied how it passes part of its beginning life in the ants and then it makes the ants go crazy, so that they climb on the the tip of grass and wriggled in such a way to attract the sheep to come and eat those grass-blades. Thus the worm reaches the brain of the sheep, needed for the next phase of its life-cycle.

From crazy fishes flipping on their belly on the surface of water so that they were eaten by some cranes to cockroaches meekly following the wasps to their nests so that wasp could deposit its eggs on its tummy and when wasp-babies come out they could have fresh cockroach meat, the stories are incredibly interesting and morbid.

They also made me think about some flamboyant persons with attention-seeking behaviours and wonder if they might have some worms in their brains? We do have some popular ways of sayings in Hindi in India, such as "Iske dimaag mein keeda laga hai" (His/her brain has got a worm), which sounds very similar to these stories.

Parasites and Human Behaviour

In this part of the book, McAuliff focuses on human psycho-pathology. These are more of hypothesis rather than scientific studies, about how the bacteria living in our bodies might be influencing our behaviour (though these bacteria are not really parasites, rather these are symbiotic organisms, as they get nutrition from us but they also provide benefits to us such as vitamins).

Cruickshank, in her review of McAuliff's book in New Scientist has critiqued this part:

Oblivious, McAuliffe skips into attention-grabbing territory armed with only the flimsiest of evidence. She claims, for example, that infection makes us more sociable and sexually voracious as the parasite seeks to infect others. This is based on a study that followed people given a flu shot (it being unethical to give people actual influenza). The subjects’ increased sociability might have been due to viral manipulation, but for my money it’s more likely they were simply feeling confident about being protected from infection.

McAuliff may not have evidence for most of the things she writes in this part of the book, but in terms of human psycho-pathology, they do raise some interesting hypothesis.

Conclusions

Studying the influence of bacteria and parasites on human behaviour is a field in expansion and new discoveries are already being made, which have many practical implications. For example, understanding how the malaria parasite influences mosquito behaviour and how it changes human physiology, can help us in diagnosing it and fighting against an infection which kills hundreds of thousands of persons each year. Some months ago, I had seen a TED video by James Logan about how dogs may be able to identify persons with malaria parasite, because the parasite makes our bodies secrete a chemical in our sweat, which attracts uninfected mosquitoes to come and bite us, and dogs can be trained to identify the persons with this chemical in their sweat.

I found this book hugely interesting and read it in a span of a few days, almost like a thriller. It is true that in terms of influence of micro-organisms and parasites on human behaviour, this book is speculative. However, it might influence young researchers to study these areas and see if such infections/infestations can be implicated in the causation of conditions which are yet not properly understood, like schizophrenia and Alzheimer disease.

*****

Fighting Superbugs

65 years ago when I was born, dying due to a simple infection such as diarrhoea or pneumonia was common. Our family history had numerous stories of persons dying young. At that time, average life expectancy in India was less than 38 years. While I was growing up, during 1960s and 70s, slowly we had become familiar with names of antibiotics like Tetracycline and Chloramphenicol. By the time I finished my medical college in late 1970s, average life expectancy had increased to 53 years, while the list of available antibiotics had become much longer with drugs like ampicillin, amoxicillin, erythromycin and gentamycin. Every year, new medicines were coming out. Occasionally we had infections which were resistant to some of these medicines, so we had started doing cultures to check which antibiotics could be more effective in a patient who was not responding to treatment.

In the last 50 years, the situation has changed drastically. Every now and then we hear of infections which do not respond to any medicine. Matt McCarthy's 2019 book "Superbugs: The Race to Stop an Epidemic" is about this subject.

Use of Antibiotics in Livestock

The first use of antibiotics in the livestock was approved by the Federal Drug Agency (FDA) of USA in 1951. They started to be used in small amounts in concentrated animal-feeds for growth promotion and prevention of diseases among the farm animals, especially in the poultry and cattle destined for meat production. They helped chickens, pigs and livestock to grow faster and put on weight. Since then, the use of antibiotics in the industrial production of meat has become routine.

Eating this meat introduces those antibiotics in our bodies and in the environment, promoting drug resistance in the bacteria. Already in 1969, a British committee of experts had concluded that the use of antibiotics in animals was contributing to antibiotic resistance in humans. Thus we are aware of this problem for a long time. However, its importance was under-estimated.

Apart from the use of antibiotics in the livestock, another problem has been indiscriminate use of antibiotics. Many doctors prescribe antibiotics for viral infections, even when they know that these are not useful. There is no control on the sale of antibiotics in many countries, so that people can buy them without prescription.

Antibiotic resistance and resistant bacteria both travel around the world, passing from one country to another. Thus, it is global problem affecting everyone and no one is safe from it.

Over the past decade, numerous cases of infections non responding to any medicine and leading to death of persons have brought this subject to the attention of general public. Extremely resistant cases of diseases like tuberculosis have appeared and are widely feared. The World Health Organisation has already issued some catastrophic warnings and asked for urgent search for solutions.

Matt McCarthy's Book

McCarthy's book on the subject of superbugs is written in an extremely engaging style. He works at the Presbyterian Hospital in New York, where they try to identify new antibiotics which can treat resistant infections. He explains the difficulties of treating superbugs through stories of individuals who turn up in the emergency department of his hospital. Reading the theories of antibiotic resistance is very different from reading about someone who has this infection.

For example, the story of a person, whose diagnosis of cancer has devastated his family. When it seems that chemotherapy might save him, a minor infection suddenly takes him close to death, unless the doctors can find some new treatment to treat it, but it is not responding to any medicine. McCarthy's book has a series of these real-life inspired stories, which start as a character sketch of the persons and their families and then reach a sudden turn of random events which turn their lives upside down, showing the fragility of our lives.

Once I started this book, I didn't stop reading it till 4 days later when I finished it. While I have known about superbugs and the problems of antibiotic resistance for a long time, the book explained the different challenges associated with it. Mixing of scientific information with human stories makes it very interesting. The book mainly moves around the human trials of a new antibiotic called "Dalbavancin" or Dalba. It also mentions some other new medicines and the persons involved in their research but most of its stories are of persons on whom Dalba is being tried.

Over the decades, doctors engaged in research for new medicines have not always behaved in an ethical manner. Recently, I was reading about an unethical research done by Armeur Hansen, who is known as the person who had discovered the leprosy bacillus in 1873. McCarthy shares the details of inhuman and unethical research done in the Nazi camps. Then he tells about another research carried out in Tuskegee, Alabama (USA), where hundreds of black men and women were recruited in a research, given false information and denied treatment which could have easily cured them, so that the doctors could study the natural evolution of the sexually transmitted infection syphilis. This had happened in 1950s-60s, years after the Nazi experiments.

The book also touches on the world of Big Pharma. For many years, I was part of a group fighting for people's right to health. In these groups, multinationals and especially the Big Pharma, is seen as villain, as they look only at their profit margins and are uncaring of the poor persons' need of medicines. McCarthy's book avoids painting the drug companies in black and white.

For example, McCarthy's explanation about insufficient research on new antibiotics and the role of the big Pharma is in the following terms:

Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, is the man responsible for establishing federal funding priorities for research on antibiotic resistance, and he told me that developing new drugs is, in fact, one of his top priorities. But the situation is complicated. “You don’t want the federal government to be a pharmaceutical company,” he said, “because you’d have to build an entire industry, and that would divert away from what the government does well, which is scientific discovery and concept validation. We need a partner.”And that partner, for better or worse, is Big Pharma. “If the federal government tried to re-create Merck,” Fauci said, “it would cost billions of dollars. The expertise of production, filling, packaging, and lot consistency. People take that for granted, but that’s an art form that has been perfected by these companies, not the government.”The problem, ultimately, is that many antibiotics are not very profitable. When a new drug emerges from an idea, there’s a step-by-step process that costs upward of a billion dollars to bring it to market. If that leads to Viagra, the expense is justified because you’ve just made a multibillion-dollar drug. With an antibiotic, however, the profit margins are narrow because of three characteristics: they’re usually given in short courses, they’re prescribed only when someone is sick, and sooner or later even that terrific new antibiotic is going to develop drug resistance. The latter is not a matter of if but when. “The incentive to make major investments in antibiotics,” Fauci told me, “is not something that attracts the pharmaceutical industry, so how do you get around that?”

The book is also an ode to McCarthy's senior colleague and mentor, Tom Walsh , director of the Transplantation-Oncology Infectious Diseases Program, who seems to live only for his work and does it with great empathy. It is difficult not to share McCarthy's admiration of such a wonderful human being and professional, and wish that if one day we would find ourselves in a hospital, we shall have a doctor like him.

Apart from his skills as a clinician and researcher, McCarthy also has a way with the words. For example, he introduces Tom Walsh with the following words:Walsh is a wisp of a man, pale and thin like a potato chip, with deep-set eyes, a warm smile, and a surprisingly firm handshake. His modest features are a notable contrast with my own: I have a high forehead, broad shoulders, and a nose that’s slightly too large for my face. We make for an odd pair.

Conclusions

I love reading books about health and medicine. These give an overview of the issues in a way which is impossible in the medicine textbooks, which limit themselves to dry facts - symptoms, diagnosis and treatments. On the other hand, a good book on medicine aimed at general public, provides a glimpse into its history and how our understanding about the disease condition changed over a period of years or decades.

For example, I have been really impressed by a couple of books on psychiatry and autism, which I had read recently - they had opened the doors to a largely unknown world to me. "Superbugs" by Matt McCarthy didn't have the same impact, because I was already familiar with some the ideas and questions it discusses. However, I loved reading it and will recommend it to everyone for gaining a deeper understanding about an important subject, in an engaging way.

Note: In 2019, after writing this post I had contacts with Dr Abdul Gafoor who told me about the WHO initiative on antibiotics resistence and that spread of resistant strains through lack of sanitation was a much bigger contributing factor compared to the irrational use of antibiotics. He referred me to his article in The Hindu, from which the following excerpts are presented below:

"... back in 2010, people like me sincerely believed that AMR was caused primarily by the misuse of antibiotics by the medical community. We all wrote a few lines about infection control, but 90% of our articles, research papers was about irrational antibiotics usage. I did not write about environmental sanitation. I did not write about most of the things that I know today, because that the concept has changed over the last 10 years. At that time, we thought that antibiotic stewardship was the most important component in tackling AMR, along with infection control, and then made a mention of the importance of sanitation. Now if you ask me, what is the most important component of tackling AMR, I will say in a developing country such as India – it is sanitation. I will put sanitation right on top, then I will put in infection control, and then, antimicrobial stewardship, rational antibiotics usage - whether at the hospital or over the counter.

Why? Thanks to scientific evidence that has emerged, since, and changed our perspective. A commentary published in Antibiotics, an open access journal, recently showed that AMR rates were found ‘positively correlated with higher temperature climates, poorer administrative governance, and the ratio of private to public health expenditure.’ When a more complex analysis was done, then better infrastructure (e.g., improved sanitation and potable water) as well as better administrative governance (e.g., less corruption) were strongly and statistically significantly associated with lower AMR indices. And this is significant: the comment stated that ‘Surprising, and contrary to most current beliefs, antibiotic consumption was not strongly associated with AMR levels. This empirical evidence implies that contagion, rather than antibiotic usage volumes, is the major factor contributing to the variations in antibiotic resistant levels across countries.’"

*****

#bookreview #antibioticresistance #mattmccarthy

Lessons of Life from Adam Smith

Adam Smith is considered to be the father of liberal capitalism and free markets. His book "The Wealth of Nations" is considered as one of the most influential books on economics. Smith had written another book, "The Theory of Moral Sentiments", which is hardly remembered today, which was about human nature and how to live a fulfilling life. Russ Roberts' book "How Adam Smith can change your life" is a reflection and analysis of this lesser known book of Smith.

This post is about the book "How Adam Smith can change your life - An Unexpected Guide to Human Nature and Happiness". The book is full of interesting insights about human nature and why we behave the way we do. In this post I am going to focus on only 2 ideas of this book.

Self-Deception & Confirmation Bias

According to Smith, human beings are self-centred. For us our own life problems are much more important compared to big tragedies befalling humanity in some far away place.Human beings also have a big capacity for self-deception, sometimes unconsciously, so that we find an excuse to do things without listening to the voice of our self-conscience. Russ writes about this self-deception:

Rather than see ourselves as we truly are, we see ourselves as we would like to be. Self-deception can be more comforting than self-knowledge. We like to fool ourselves. 

When we behave in selfish and self-serving ways, sometimes we even justify it by saying that we did it for altruistic reasons, to help others. We describe our selfish actions in selfless language. According to Smith, we do this not only to convince others but also to convince ourselves, so that we can continue to hold a positive image of ourselves in our minds. According to Smith, our behaviour sometimes falls short of our ideals not because we’re bad people and not because our self-interest outweighs our benevolence, but because of what is called the "confirmation bias" - we don’t realize that we’re not living up to our ideals.

A modern name for Smith’s insights about self-deception is confirmation bias. Confirmation bias happens when we filter reality through our biases, ignoring evidence that challenges or refutes what we believe and eagerly accepting evidence that confirms what we believe. ... Another modern name for the challenge of understanding our complex world with any precision comes from Nassim Taleb—the narrative fallacy. We like narratives that follow a nice, clean pattern. Evidence that fits the narrative is noted after the fact. Other evidence that doesn’t fit the narrative is discarded.  
Among the persons offering advice motivated by self-interest and camouflaged as altruism, there are some examples of doctors, which brought to my mind many instances of distorted private medical services. For example, private nursing homes have much higher rates of Caesarean section instead of normal deliveries. Heart specialists in private hospitals advise much higher numbers of coronary artery bypass operations. I believe that this is a mechanism of self-deception, so that we doctors convince ourselves that we are not doing it for money but these operations are for benefiting those persons. However, this is not just about doctors, it is true for all kinds of professionals and private businesses. They don't see themselves as dishonest, many of them may be convinced that they do it to help others.

Everyday Actions Creating Civilization

The second idea from Smith that I want to touch in this post, is about small or minor actions by each of us, which taken alone are insignificant, but combined with similar actions of millions of other persons, together create the norms of our societies. Russ calls it this process, the "Emergent Order".

The economist Milton Friedman captured this strange paradox of small effects amounting to something significant when he said about supply and demand that the sum of negligible forces need not be negligible. So while my demand for apples has no impact on the price of apples, our demands all together, along with the decisions of suppliers, are what determine the price of apples. Not the greed of the grocer down the street, not my desire to get a good deal, but all our interactions together. And even though any one apple eater has no measurable or noticeable effect on the price, because she contributes an insignificant portion of the total demand for apples, apple eaters as a group have a very significant effect.Thus, Smith says that with our individual choices can lead to important social outcomes and this is how we create our society including our norms about morality, mutual trust and civilized behaviour.

This part of the book stimulated me to think about the kind of societies we are creating today. I think that when we choose our leaders and celebrities who behave in a certain way, they amplify the actions of their followers and thus determine the civilizational norms of our society. Through social media, such as Facebook and Twitter, these followers amplify their messages and gain strength from each other. The confirmation bias helps them to not see or listen to anything which does not fit in with their ideas. Thus, people with different ideas on the left and right of political spectrum, remain in their own circles and increasingly express themselves in ruthless and brutal terms, unable to see that they are mirror images of what they wish to fight.

At the same time, there is increasing acceptance of more extreme ideas. For example, when the news came about the sinking of a boat full of emigrants, some persons who are against emigrants, wrote on Twitter that it was good for feeding the fish. I think that this kind of thinking goes beyond being against emigrants - such ideas denote psychopath personalities. Thus, we creating societies where such expressions are acceptable, and persons can openly express such opinions without feeling ashamed about them. Across the world we have many political leaders, who encourage such ideas, sometimes using religions to justify them.

Conclusions

Adam Smith had written his book "The Theory of Moral Sentiments" in the mid-18th century and the original book is not so easy to read. Russ Roberts' book "How Adam Smith can change your life - An Unexpected Guide to Human Nature and Happiness" explains its ideas in an easier to understand manner. As you can see from my reflections above, these ideas from 18th century are still valid and have much to teach us. I think that Russ Robert's book is one of the more interesting books I have read recently.

*****

#adamsmith #russroberts #bookreview

Disturbances of Brain & Mind: The Psychiatry Story

Jeffrey A. Liberman, a professor of psychiatry at Columbia university (USA), has written, “Shrinks – the Untold Story of Psychiatry” (Little Brown and company, 2015). Psychiatry is the branch of medicine which deals with mental illness. It is a poorly understood area, not just for common public but also for some doctors like me. I found the book fascinating and read it in almost one sitting.

In this post, I am going to write about some of the key things I have learned about mental illness and psychiatry from this book.

Mental Illness

Mental illness is unlike any other illness – it is a medical illness (something to do with our body, especially with our brain and its functioning) and it is also an existential illness (something to do with our thoughts, feelings and emotions). Each kind of mental illness is composed of a cluster of symptoms, that may be present in a variable pattern and severity in individual persons.

The 3 most common kinds of mental illnesses are – (1) Psychosis such as schizophrenia (loss of touch with reality, confused thinking, hearing voices or seeing things, having strange beliefs);(2) Depression (feelings of apathy, sadness and uselessness); and, (3) Mania or bipolar disorder (characterised by extreme mood swings).

Personal Experiences

When I studied medicine in the 1970s in India, I found that psychiatry was a little confusing. It had a lot of Freud and his theories about our repressed sexual desires and it had a few medicines for conditions like depression. I could not make any sense out of it and I was sceptical about the explanations of Freud as the causes of mental illness.

During the early 1990s, I started dealing with community-based rehabilitation (CBR) programs and came across two terms - 'mental illness' (strange behaviour) and 'mental disabilities' (such as low IQ and learning ability). In the communities, people used words like 'crazy' and 'idiots' for these two conditions. However, the affected persons found these colloquial terms negative and extremely hurtful. They taught me to use more neutral words such as persons with mental illness or learning disability.

I have also known some persons who define themselves as 'Survivors of Psychiatry', who do not like psychiatry and do not believe in its usefulness. They feel that psychiatry is a kind of conspiracy theory to control people and they say things like – "psychiatric medicines are useless, they are used only to make rich the Big Pharma; they take perfectly normal behaviours and call them illnesses to give them medicines; their drugs and treatments destroy people’s brains."

Negative Reputation of Psychiatry

Lieberman owns up immediately that for this negative reputation, psychiatrists themselves are to be blamed, “There’s good reason that so many people will do everything they can to avoid seeing a psychiatrist. I believe that the only way psychiatrists can demonstrate just how far we have hoisted ourselves from the murk is to first own up to our long history of missteps and share the uncensored story of how we overcame our dubious past ... Psychiatry’s story consists mostly of false starts, extended periods of stagnation, and two steps forward and one step back.”

From the start of the nineteenth century until the start of the twenty-first, each new wave of psychiatric sleuths unearthed new clues—and mistakenly chased shiny red herrings—ending up with radically different conclusions about the basic nature of mental illness, drawing psychiatry into a ceaseless pendulum swing between two seemingly antithetical perspectives on mental illness: the belief that mental illness lies entirely within the mind, and the belief that it lies entirely within the brain. … Psychiatry, on the other hand, has struggled harder than any other medical specialty to provide tangible evidence that the maladies under its charge even exist. As a result, psychiatry has always been susceptible to ideas that are outlandish or downright bizarre; when people are desperate, they are willing to listen to any explanation and source of hope.
The term “psychiatry”—coined by the German physician Johann Christian Reil in 1808—literally means “medical treatment of the soul.” Psychiatry’s beginning is linked to a German named Franz Anton Mesmer in the 18th century, who rejected the common ideas of divine punishments and sins as cause of these disturbances and suggested that they were caused by the blockage of an invisible energy running through magnetic channels in our bodies. He called this energy 'animal magnetism'. Though his ideas about the invisible energy were wrong, but this was the beginning of looking for causes of mental illness inside ourselves.

Over the next 200 years, many other persons such as Benjamin Rush, Julius Wagner-Jauregg, Manfred Sakel, Neil Macleod, Walter Freeman, Melanie Klein and Wilhelm Reich, came up with similar theories about causes of mental illnesses, each of which resulted in its own treatment, which became famous for a period but was actually ineffective. Some of these treatments had mortal side-effects and none of them had any empirical basis.

Theories of Sigmund Freud

The most influential among these theories about causes of mental illnesses were those advanced by Freud (1856-1939) in early 20th century. His most celebrated book was, The Interpretation of Dreams, which explained the role of subconscious mind and its unresolved conflicts, leading to mental illness. Freud divided the mind into different levels of consciousness - 'id' (source of instincts and desires), 'superego' (voice of conscience) and 'ego' (everyday consciousness).

These ideas revolutionised psychiatry and became the dominant way to understand and treat mental illnesses. Like the other theories mentioned earlier, even Freud’s theories did not have any empirical evidence and psychoanalytical approaches helped few, if any, persons with serious mental illnesses.

Freudian treatment required the doctor to remain remote and impersonal. As recently as the 1990s, psychiatrists were still being trained to stay aloof, deflecting a patient’s questions with questions of their own. About Freud, Lieberman writes, “Freud did teach me the invaluable lesson that mental phenomena were not random events; they were determined by processes that could be studied, analysed, and, ultimately, illuminated. Much about Freud and his influence on psychiatry and our society is paradoxical—revealing insights into the human mind while leading psychiatrists down a garden path of unsubstantiated theory.”

New Psychiatry After Second World War

Till 1940s, there was no other way to treat mental illnesses except for Freud’s psychoanalytic approach. The first medicines for treating the three most common mental illnesses were all discovered after the second world war - Chlorpromazine for treating psychosis, Imipramine for treating depression and Lithium Carbonate for treating the bipolar disorder.

The impact of these medicines was dramatic. For example, Lieberman evokes the impact of using chlorpromazine with the following words.

“On January 19, 1952, chlorpromazine was administered to Jacques L., a highly agitated twenty-four-year-old psychotic prone to violence. Following the drug’s intravenous administration, Jacques rapidly settled down and became calm. After three steady weeks on chlorpromazine, Jacques carried out all his normal activities.” It is hard to overstate the epochal nature of Laborit’s discovery. Like a bolt from the blue, here was a medication that could relieve the madness that disabled tens of millions of men and women—souls who had so very often been relegated to permanent institutionalization. Now they could return home and, incredibly, begin to live stable and even purposeful lives.

During 1960s, another researcher-psychiatrist Eric Kandel, showed anatomical changes in brain linked with memory and opened the pathway to the understanding of biological causes of mental illnesses in the brain. During the 20th century, the only way to study brain was through autopsies and brain operations. After Kendel, a large number of biologists, geneticists, neurologists and other scientists, using other innovative technologies such as MRI, started studying brain and its functioning in live persons, providing new insights about mental illnesses.

The 3rd area of big change which initiated in the 1960s and has now become widespread, is to move away from psychoanalysis as suggested by Freud, and replace it with psychotherapies starting with Cognitive Behaviour Therapy (CBT) pioneered by Tim Beck. The unexpected success of CBT opened the door to other kinds of evidence-based psychotherapy such as interpersonal psychotherapy, dialectical behavioral therapy and motivational interviewing.

Future of Psychiatry

Lieberman proposes a pluralistic vision of psychiatry: “Mental illness is not only biological and is not only psychological – it involves both brain and mind in different ways. Treatments include psychotherapy and psycho-pharmaceuticals.” He also lists some of the promising areas of research which should improve the impact of psychiatry in the future - genetics (how certain patterns or networks of genes confer different levels of risk), new diagnostic tests for mental illness (including genetic tests, electrophysiology-tests, serological tests and brain imaging tests), and new developments in psychotherapy based on cognitive neuroscience.

Some researchers are combining psychotherapy with medicines to increase their impact. Drugs that enhance learning and neuroplasticity can increase the effectiveness of psychotherapy and reduce the number of sessions necessary to produce change. For example, cognitive-behavioural therapy (CBT) can be combined with D-cycloserine, which enhances learning by acting on glutamate receptors in the brain, and strengthens the effects of CBT.
Internet-based applications for mobile devices that assist patients with treatment adherence, provide auxiliary therapeutic support, and enable patients to remain in virtual contact with their mental health providers, are another area for the future development.

Conclusions

I loved Liberman’s book because it gave an overview and understanding about mental illnesses and what can be done about them.
Unfortunately, strange ideas about causes of mental illnesses, not based on any empirical evidence, continue to be common even today, attracting big group of followers. Lieberman has written about the current popularity of the ideas of one such person (Daniel Amen) and his propagation of another theory which is not based on any empirical proof. Charismatic persons have always had this power to make people believe in their extravagant ideas and only time shows that their fame was built on a false premise.

The book made me understand that boundaries between what I understood as “mental illness” and “mental disabilities” are porous and dynamic. Even my notions of separating “neurosis” (mental illnesses where persons do not lose touch with reality) and “psychosis” (mental illnesses where persons lose touch with reality) are not very useful categories. Similarly, it is no use looking for the right answer to mental illness in only medicines or only psychotherapy - a pluralistic vision where both medicines and psychotherapy may play a role can be better.

*****

Note: The two images used in this post are from a "dance therapy" session for persons with mental illness in Brazil

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