Merry Christmas Or Seasons' Greetings?

A few days ago, one morning I read two articles which made me reflect on the two different ways in which multi-cultural and multi-religious societies can look at inter-faith dialogue, respect and harmony.

In this post, I am going to talk about these 2 different ways of looking at religious differences and what we need to do for living with a diversity of beliefs.
The Two Articles

Let me start with the 2 articles which had stimulated this reflection. The first was an article in a recent issue of Readers' Digest magazine. Actually it was not an article but a snippet under the heading "Your True Stories". I am transcribing that snippet here:

Last December, a young lady ringing up my purchases greeted me with an enthusiastic Merry Christmas!” I was not offended, but I am a Muslim, and at the time I was wearing a beautiful headscarf in a manner identifying my spiritual convictions. I responded, “Happy birthday!” At first, she was taken aback, but then she nodded and laughed good-naturedly, acknowledging my point. I smiled back at her and said, “Merry Christmas to you.”

The second was an editorial in the Indian newspaper Hindustan Times, written by Mr. Rajmohan Gandhi, the grandson of Mahatma Gandhi, under the title "In Memory of Frontier Gandhi, a Plea for Justice for Faisal Khan". It mentioned the story of Khan Abdul Gaffar from Peshawar, now in Pakistan, and his organisation called Khudai Khidmatgar, which worked for promoting Hindu and Muslim unity. Khan Abdul Gaffar was also known as Frontier Gandhi and I have memories of meeting him as a child in Delhi in early 1960s at the home of Dr. Ram Manohar Lohia, the charismatic leader of the India's Socialist Party. This article is about a person from Delhi, Mr. Faisal Khan, who has an organisation in India inspired from the ideals of Frontier Gandhi. It described Faisal with the following words:

Faisal Khan has striven without pause for two goals — communal harmony and relief for the neediest. He is also a wonderful singer of the Tulsi Ramayan. Hindus of all types, from venerated guru to college students, have been charmed by his rendering of the Ramayan’s verses. Keen, as part of his efforts towards harmony, to identify with the traditions of his Hindu friends, Khan, along with associates, recently performed the much-valued Braj Parikrama. On the last day of this 84-km yatra, they went to Mathura’s Nand Baba Mandir, where they were courteously received by the priest.
Reading these 2 articles, made me reflect about the two approaches to inter-faith harmony.

Multicultural Approach to Inter-faith Harmony

I think that first article represents the multi-cultural approach to inter-faith harmony, which arose in UK or perhaps in Western Europe. Now this approach seems to be common in the West (Europe, USA and Australia). It is slowly making inroads even in countries like India, at least among some academic and activist groups. It asks individuals to respect the diversity of religions of others, by not offending them by involving them in things related to other religions. Thus, if we are Christians, it says that we should not have overt signs celebrating Christmas or Easter in public spaces and schools. If we have to greet people we do not know, we should use generic terms like "seasons' greetings" and to not "merry Christmas", for not offending non-Christians. People who believe in this approach, talk of tolerance and respect for other religions.

If we believe in this approach to inter-religious relations for harmony, then if we are Muslims, we won't make Eid or Ramazan greetings to the non-Muslims and if we are Hindus, we would greet only other Hindus on our festivals.

Indian Approach to Inter-faith Harmony

When I grew up in India, our approach to diversity of religions was different. While in school, we had holidays for the festivals of all the religions. Since early childhood, I was used to meeting persons of different religions among neighbours, friends and in public spaces.

Over the years, we lived in different houses, where we had as neighbours families of different religions. Even at home, among the socialist friends of my father who visited us included persons of different religions. During our travels, I had stayed at the homes of family friends of different religions.

When I think of those years, it is remarkable that I can't remember ever thinking about the diversity of religions of all those encounters in India. I had been familiar with news of riots and religious riots, but somehow they had no real bearing with my relationships with persons of different religions. My first actual encounter with the underlining of and impact of diversity of religions happened in Italy, when a high school student asked me if I believed in Madonna. I had told him that I was a Hindu. He did not know any Hindu but he knew about protestants and that question was his way of reassuring himself that I did not deny the sacredness of Madonna. When I told him that I respected Madonna, he was reassured.

The basic understanding governing the multi-religious relationships in the India of my childhood was that all religions are about the one and the same God. Therefore, festivals of all the religions belonged to everyone. Having school holidays for all those festivals reinforced that feeling. So it meant, waking up at early morning to go out and stand on the side of the street to wait for Prabhat Pheri of the Sikh when they celebrated their Gurupurab. It meant wishing everyone Eid Mubarak and eating the sweet sewaiyan, that our neighbour Irene brought to our home. It meant going with my Catholic friend to the midnight mass in the Cathedral on the Christmas eve. It meant going into Buddhist temple to pray to Buddha. And, it meant, saying Happy Diwali to everyone and offering them sweets to celebrate the Hindu festivals.

In that India of my childhood, the idea of "tolerance" in reference to other religions, would have been kind of insulting, because we were expected to share the joy and sacredness of each religion and not just "tolerate" them

Which Approach Do You Prefer?

I think that with some exceptions, increasingly the modern world is going towards less orthodox religious beliefs. A large number of my friends and members of my extended family in India, do pray in temples and homes, but they are equally respectful of other religions. There are four inter-religious couples among my cousins' families. My own family is also inter-religious. With time, I expect that religious diversity in our family is only going to increase. This means that we shall have more occasions for celebrating festivals and also picking and choosing some aspects of ideas and practices of other religions in our daily lives. This seems to be in line with the ideas of inter-religious harmony with which I had grown up in India.

It is true however, that even in India, I feel that compared to my childhood, today many groups of persons are more polarised in terms of religions. Though a lot of persons continue to value respecting and sharing among persons of different religions, those with polarised thinking speak louder and dominate many forums. Fortunately, India continues to have a lot of mixed religious spaces formed by inter-mixing of persons of different religions.

I think that the ideas of multi-culturalism approach to inter-religious relations in Europe and America, which are focused on "not offending those of other religions", are a result of increased encounters after the second world war and due to a globalised world, between the more secularised and less religious populations in the West with more conservative minorities, often immigrants, who feel that they need to hold on to their specific identities, for not getting lost in their new lands. Thus, I feel that it is an expression of cultural anxiety.

In many ways, these inter-cultural encounters are also shaped by identity politics and ways of reading all relationships in terms of dominance and oppression. Perhaps historians can tell us from the experiences of the past, how such encounters between people of different cultures can evolve and resolve?

Which of these two approaches to inter-religious harmony do you prefer?

Conclusions

From the way I talk about the Indian way of looking at the diversity of religions, it must be obvious that I prefer this approach to inter-faith harmony. At the same time, after my travels across different countries and encounters with a diversity of religions and cultures, I must acknowledge that many persons feel threatened or at least uncomfortable if they have to accept close contact with other religions. I try to respect their diffidence, though I must confess that I can't really understand their anxieties.

I also try that I continue to deal with persons of different religions in my way. I go rarely to the mass in a church, but when I do, I am happy to bow my head and pray. I am not very religious, and while visiting temples, churches, gurudwaras and sufi dargahs, I try to feel the sacredness of their ambience and prayers. I also wish Eid Mubarak or Merry Christmas or Happy Deewali or Happy Navroz, to all my friends at the festival times without worrying if they are Hindu, Muslim, Jew, Christian or Sikh. However, if I know that a person does not appreciate receiving greetings for festivals of other religions, I try to be respectful of their choice.

I know that we live in polarised times. For whatever reasons, some people have become more aware of religious differences and at least some of them, do not wish to celebrate the festivals of others or to visit the others' prayer places. At the same time, I often find many persons who think about different religions like me, they are happy to listen to religious ideas of others and do not get offended by religious differences.

Personally, while each one of us is secure in his or her own religion, I would prefer a world of acceptance, respect and joy towards all religions. I know that it is an utopia, but I like utopias.

A final note about Mr. Faisal Khan mentioned above: I have read that Mr. Khan was arrested on 2nd November 2020 for offering namaz in the courtyard of a Hindu temple in India, though it was the temple priest who had suggested to Mr. Khan to pray there. I think that a Muslim singing Ramcharit Manas and praying in a Hindu temple can happen only in India because of this approach to inter-religious harmony that I am talking about. It is an embodiment of the Indic thinking which sees different religions as paths to the same God.

I hope and pray that better sense will prevail and Mr. Faisal Khan can be released.

***

The Angry Birds - About Books & Birds

This month our reading group in Schio (Italy) had decided to read The Bird by the British author Daphne du Maurier. The long-story written in early 1950s was turned into an iconic horror film of the same name by the celebrated film-maker Alfred Hitchcock.

Being a part of a Book-Reading Group has substantially changed the way I read some books. First of all it forces me to read books that otherwise I would not read. For example, usually I don't read horror books - they make me too anxious and afterwards I can't sleep. So by myself, I would not have read du Maurier's book.

"The Birds" was not too bad in terms of its horror-impact, probably because I interacted with it differently from the way I usually read books. I read it more critically and consciously, so I felt less immersed in its imagined-world. If you read a horror book without letting yourself get lost in it, probably you enjoy it less and at the same time, it does not affect you in the same way - at least, that's how I felt about it.

As a part of being more critical and aware while reading a book for our group, I also write down notes about the ideas that it provokes, which I rarely do while reading others books. During normal reading, those ideas are fleeting like dreams which I forget the moment I turn the page. By taking notes those fleeting ideas are marked deeper in my mind, and I can reflect about them. That is how this post came around, to share some of those ideas which came to my mind, while reading "The Birds".

The Birds by Daphne du Maurier

The story of this book is about millions of birds suddenly turning into killer machines who want to murder humans. The first thought that came to my mind while reading it was about the video-game "The Angry Birds", which was supposed to be very popular some 10 years ago. I am not a fan of videogames and I had never tried playing The Angry Birds, but I knew that it was about birds attacking some pigs who had robbed the bird-eggs. A TV serial and a film were also made about it. So the question in my mind was, did this book (or the film based on it) in any way inspire the videogame makers?

The second aspect which struck me was about some of the parallels between the descriptions in the book and the present situation of Covid-19. The first line of the story "On December the third, the wind changed overnight, and it was winter" seemed like a description of the suddenness of the pandemic. The phrases about cold autumn winds sweeping away the yellow-brown leaves, seemed a metaphor of the old and sick persons succumbing to this virus. While, the reactions of the farmer Trigg and his family in the book, reminded me of those who do not believe in the pandemic, think that it is some kind of corporate conspiracy and who refuse to wear masks or take precautions. For example, read the following paragraph from the book: "He tried to tell Mrs. Trigg what had happened, but he could see from her eyes that she thought his story was the result of a nightmare. “Sure they were real birds,” she said, smiling, “with proper feathers and all? Not the funnyshaped kind that the men see after closing hours on a Saturday night?” Mrs. Trigg, “no explaining it, really. You ought to write up and ask the Guardian. They’d have some answer for it. Well, I must be getting on.”

I was also struck by the names of a large number of birds in the story - blue tits, robins, wrens, thrush, blackbirds, house sparrows, pigeons, starlings, black-headed gulls, rooks, crows, jackdaws, magpies, jays, gannets, hawks, buzzards, kestrels, falcons, finches, larks, oystercatchers, redshanks, sanderlings and curlews.

Did the British people in the 1950s know and could identify so many birds? I think that 70 years ago, with lesser urbanisation, there was greater awareness of the nature among people, which is difficult today. It made me think of the night skies of my childhood and the way I used to search for and look at different stars and constellations - now the streetlights and city lights are so strong that even when you do look up at the night sky, you can hardly see any stars. Like the names of the birds in the book, probably I can recite a much larger number of names of stars and constellations compared to an average person from today's generation!

If this book was written today, in which ways it would have been different from the book of Du Maurier? For example, read the following passage about Nat, the hero of the story, finding the sea full of seagulls: "Then he saw them. The gulls. Out there, riding the seas. What he had thought at first to be the white caps of the waves were gulls. Hundreds, thousands, tens of thousands . . . They rose and fell in the trough of the seas, heads to the wind, like a mighty fleet at anchor, waiting on the tide. To eastward and to the west, the gulls were there. They stretched as far as his eye could reach, in close formation, line upon line. Had the sea been still, they would have covered the bay like a white cloud, head to head, body packed to body. Only the east wind, whipping the sea to breakers, hid them from the shore."

In the story, when Nat sees them, he thinks of going "to the call box by the bus stop and ring up the police". Today we do not have "call boxes", we all have our mobile phones, but if you do find the sea full of gulls, what would you do? I bet that 99% of us would click pictures and share them on WhatsApp with their families and friends. A fair number would put them on Facebook or Twitter or Instagram, and many of us would try to get a selfie with those gulls in the background. If the author was writing this story today, probably Triggs and his wife would be shown dying while trying to click a selfie.

The story also made me think of our local popular dish in this part of Veneto region in Italy where I live, called "Polenta e Uzzei", which is corn-cake with roasted small birds. The scene in the book in which burnt dead birds fall down in the fire under the chimney, reminded me of lunches in a friend's home, who loved hunting birds and then roasted them on the hearth along with the corn-cake. I thought that this story was written especially for people who love eating those tiny birds, because it absolves them of the guilt for killing them. I mean, if those birds are actually killers and a danger to the nice humans, it is good that one can kill them and eat them.

Classifying Horror, Terror, Fantasy Genres of Books

During the discussions in our reading group, one of my friends, Michela, said that the story was not really a "horror book" but rather a "terror book". I could understand her point because it is that sense of terror and fear which stops me from reading this kind of books.

After the discussions, I was thinking about how we classify all these different and yet similar genres of books. Classifying them into genres like horror, thriller, fantasy, action and mysteries is difficult because they often overlap. A common element of all these books is the sense of tension and dread which they create. Personally, I like reading action thrillers and some murder mysteries, though I have less patience with Agatha Christie kind of cerebral mysteries. I avoid books with supernatural elements, zombies, splatters and gory violence, while I get bored with books about vampires, werewolves, shape-shifters and most fantasy books.

Some months ago, I had a small Facebook discussion with a friend Francesca, where she had written about Stephen King. She is a well-known translator of books from English to Italian and has translated many Indian authors. I told her that I had never read any book of Stephen King because his books are about horror. She said that King is a master story-teller and the way he develops characters is wonderful, so for her, thinking of his books as mere horror books would be reductive. Thus, I have decided that I should try to read at least one of them before making a judgement. (P.S. Jan 2023 - I have read a couple of Stephen King books and I agree with Francesca, they are very engaging and very much different from what I was imagining!)

While I don't like horror books and films, if their horror is so exaggerated that it become kitsch, I like them. For example, I had liked watching the South Korean film "Train to Busan".

Like "The Birds", this specific genre of horror, where the ordinary things/beings become menacing raises another question about the psychology of their writers in my mind. "The Birds" turns nice little chirping birds into killers. Others have written books which turn clowns, toys, dolls, insects, or even flowers into killers. So, I wonder if these authors have some psycho-pathological problems, which makes them find fear in the beauty? What do you think?

Conclusions

If it was not for our book-reading group, I doubt if I would have read "The Birds", and even if I would have read it, I doubt that I would stopped for 5 minutes to reflect about it. I would have certainly not written a blog post about it. Slowly, I am becoming aware about how reading books for the group is changing me a reader. I think that if you have to teach creative-writing or literature-appreciation, that would also change the way you interact with books. Is that a good thing? By not allowing ourselves to get immersed in the imaginary worlds dreamt by writers, do we lose our enjoyment? I think that it would be an interesting discussion.

I feel that if it is not exaggerated by over-thinking about the books we read, to some extent becoming a more aware reader and occasionally stopping to reflect on what we have read and to talk about it with others is a good skill for today's fast-running world. I am glad that I am part of our book-readers' group!

Note: With this post, I have used pictures of 2 birds which are considered ugly and, in some ways, inauspicious by many persons, though I like them - the crow and the Brazilian Urugu vulture. Both the birds are scavengers, they eat the leftovers, keep our environments clean and live close to human settlements.

***

Poverty, Disease & Disability

The links between poverty, diseases and disabilities are well known. These links can work in complex ways. This post is about studies in Brazil showing how Zika virus infection in pregnant women combined with a neurotoxin in contaminated water in drought affected areas to increase the incidence of microcephaly (smalll, less developed brain cortex) in their newborn babies, leading to cognitive disabilities.

Understanding how different factors combine together to produce an effect is important since it helps us to look for specific solutions even while we work to remove systemic disparities linked with poverty.

Zika Infection in Brazil

Though Zika virus had already been identified in 2013, it suddenly burst out as an epidemic in Brazil in 2014. Over the following 2 years, the disease quickly spread to many other countries of the Americas and pacific. The disease is transmitted mainly through a mosquito (Aedes aegypti), and also by sexual contacts and blood transfusions. That same mosquito is also responsible for spread of other diseases like Dengue, Chikangunya and Yellow Fever. Initially it was thought that Zika infection did not cause any serious complications, till October 2015 when first reports of children born with microcephaly started coming among the pregnant women who had had Zika infection. Within a month, the number of children born with microcephaly had increased ten times. Many other newborn children had other neurological problems. Other complications of Zika included congenital malformations, and paralysis due to Guillain-Barre syndrome.

By early 2017, the number of new cases of Zika had started decreasing all over, even if different countries keep reporting occasional cases. For example, in 2018, Rajasthan in India had reported a Zika outbreak. Different aspects related to this infection remain unclear including the reasons which had led to its sudden and explosive growth in 2014-15.

Drought and Water Contamination in Brazil

The Zika epidemic had coincided with a period of drought in the north-east of Brazil. With lack of rains and evaporation of water, the concentration of salinity and minerals in the water-bodies had increased, creating favourable conditions for the growth of Cyanobacteria. These bacteria produce a chemical called Saxitoxin, which damages the nerve cells. Shell fish from the water-bodies in the drought areas had higher concentrations of Saxitoxin.

Zika and Saxitoxin

An article in June 2020 issue of The Scientist explains how Zika infection had combined with Saxitoxin to increase the number of newborn children having microcephaly. It says, "While the incidence of Zika was higher in other regions of Brazil, the number of children being born with microcephaly was higher in the north-east." Fortesting, researchers infected neural cell-cultures with Zika and then exposed them to low concentrations of Saxitoxin. They found that brain cells exposed to both Zika and Saxitoxin had 2.5 times more dead cells and three times higher number of Zika virus. This meant that Saxitoxin increased virus replication and worsened its impact on the brain cells. These findings were also confirmed in animal studies.

This research also underlined the links between poverty and disability. Poor persons with Zika infection were more exposed to drinking of contaminated water and thus were disproportionately hit by higher numbers of children with microcephaly and other congenital neurological defects leading to cognitive and intellectual disabilities.

Conclusions

This case-study shows that natural conditions such as droughts can change the risks of contamination. In such situations, policies such as privatisation of water resources lead to negative consequences which disproportionately affect the poor families. For example, drinking water from deep tubewells, has created similar risks by arsenic contamination of the ground water in Bangladesh and some parts of India, which also disproportionately affects the poor.

Case studies like this are important to understand the different ways in which diseases and other negative environmental conditions can combine and cause diseases and disabilities, especially among the poor.

*****

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.

*****

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

Accessible Children's Park in Schio

I had heard about the construction of an accessible children's park in our city Schio. I like going around on my bicycle and I had tried looking for that park a few times, but had not managed to locate it. Finally, yesterday during an evening walk with my wife, we found it.

This post is about this new park of Schio (VI, Italy), which is accessible to both adults and children with disabilities. It is a park for all, no one is excluded.

Right to Play

Article 31 of the U.N. Convention on the Rights of the Child (1989), states that all children have a right to leisure, play, and participation in cultural and artistic activities. Irrespective of country, culture, religion, and social status, all children have always played from prehistoric times. You just need to look at baby animals to understand the importance of play in their growth and well-being. Yet, few persons think about children with disabilities and their right to play. Accessible playing grounds and parks are needed so that they can be children like all the others.

Lack of play opportunities and social interaction with other children hampers the proper development of children with disabilities.

Even adults with disabilities need accessible playgrounds for their children, so that they can accompany their children and play with them like all other parents.

An Accessible Park and Playground

An accessible park and playground does not have stairs or narrow gates at the entrance. If it has stairs, it also has a ramp for the wheel chairs. Inside the park, there are suitable paths for wheel-chairs and crutches and persons with mobility problems. For the blind and low vision persons, the paths are well-marked and easy to see. At the path crossings, to help the blind persons, there are suitable surface marking which they can feel with their walking canes. Where necessary, even inside the park the stairs may be accompanied with ramps. They should have clear sign boards with both icons and texts to explain each play-structure. For blind persons recorded audio messages can also provide information.

Accessible park does not mean that every play-structure will be accessible to all the children with disabilities. There can be specific play-structures for specific groups of children with disabilities, such as the swings for children on wheel-chairs. For the use of some or most play structures, help may be needed from adults or other children, as it happens for children without disabilities. Different age groups of children may also need adult supervision.

Accessible Park in Schio

The park is located in Magre part of Schio, on Via Pio X, next to Banca Alto Vicentino. The park has been partially completed with rides and play structures, while they still need to build the Baskin court (for playing modified basketball, which can be played together by all children including those on wheel chairs or with other disabilities - it was invented in the Italian city of Cremona in 2003). It is supposed to be the biggest accessible parks in the Veneto region.

The park has a ramp for reaching the top of a slide, and each ride/play structure is marked in vivid colours. Each area is made of some soft material which acts like a cushion if you fall down. Some of the rides look strange, not usually seen in play grounds. Many of them have a futuristic look. The next time my grand daughter will come to visit me, I am planning to go back to this park and explore all these rides with her.

The park is not very well known, probably because it is not complete yet and there are no public sign boards to guide people to this place. It would be great if this park can be connected by a bicycle track or a passage to the larger park and cycle track on the other side of Alto Vicentino bank (along Via Campo Sportivo), because then more children can reach here without needing some adult to bring them here on a car.

Conclusions

I think that the idea of making an accessible park is great. City municiple government and Alto Vicentino Bank along with other partners deserve our congratulations for thinking of it.

This visit brought back a memory from Guyana (S. America) of many years ago. I had met two boys, 8-12 years old, both had a genetic muscular dystrophy, which was gradually becoming worse. The older boy was already on a wheel-chair, though he could still manage to climb stairs with difficulty. While I was talking to their grandmother, both the boys had found a slide and immediately climbed up to slide down and play (in the image below). There was no treatment for their condition and both boys were destined to get progressively worse. I remember the desperation of their grandmother and their joy in playing.

When we were visiting the accessible park of Schio, there was a man on a wheel chair with his family while a child on a wheel chair was playing on one of the rides. To see them in the park was the proof that all cities need such places, because we all have persons and children who can't enter playgrounds - they are waiting to come out of their homes and play with others.

*****

#accessibleparks #accessibleplayareas #accessiblesports #schio #italy

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

#mentalillness #psychiatry #bookreview #historyofpsychiatry

Challenges of Emancipatory Research

Recently I spoke about Emancipatory Disability Research (EDR) in a conference in Italy. This post presents some of the key points from that presentation, with a special focus on challenges of conducting EDR in a rural or peripheral area of a developing country.

This is my 7th article about Emancipatory Research and if you wish to learn more about this research approach, you can check the whole list of the articles.

EDR in Developed and Developing Countries

In 1990 Mike Oliver (1945-2019) proposed the basic idea of Emancipatory Research - A research about disability based on the social model and carried out by persons with disabilities. He suggested that such an approach will provide information which can't be provided by non-disabled researchers.

The university courses on Disability Studies starting in late 1990s, spread the idea of emancipatory research. Thus, most examples of EDR come from developed countries which run courses on disability studies. There are a few examples of EDR conducted by persons from developing countries, studying in the universities in Global North, who did their research in developing countries. Many of these were researches conducted by university-educated individuals with disabilities and involved personal stories or in a few cases, a small number of persons with disabilities.

On the other hand, the model of EDR developed in the AIFO projects in developing countries over the last 10 years, is different. Here the research is carried out in collaboration with the local Disabled People’s Organisations (DPOs), while persons with disabilities from communities are given a short training and become the researchers. Their research has a collective approach and it focuses on the main barriers they face in their lives. A process of information collection followed by reflections and collective discussions are essential parts of these EDR initiatives. I like to think of these as the Freirian model of EDR, since it seems to reflect the ideas of Brazilian Pedagogist Paulo Freire.

All my discussions in this paper are based on my experience in EDR in developing countries in the AIFO Projects.

Freirian Model of EDR

I think that before proceeding further, it will be important to understand the general process of EDR implementation in AIFO projects:

(1) It is a part of an on-going community programme. The programme staff plays a key role in initiating discussions with DPOs and other stake-holders about conducting EDR.

(2) DPOs and community organisations such as Self-Help Groups (SHGs) are used to identify persons with disabilities who will be trained, who will become the researchers and carry out the research.

Depending on the country, local context and the activities of the community programmes, the researchers can be persons with different education levels (including illiterate persons), men and women, of different age groups, with all the different kinds of disabilities and different severity of disabilities.

(3) A group of persons with different kinds of expertise are also identified to create a Technical Advisory Group (TAG), which supports the researchers by helping to plan the research and providing feedback about the research process. This group includes academic researchers and disability experts.

(4) The researchers are provided a brief training (mostly 4-5 days), focusing on examining the different possible causes of a problem, the concept of barriers and the social model of disability, how to conduct interviews, how to carry out accessibility audit, basics of ethics, privacy and bias, and how to prepare a report. The final session of the training helps them to discuss and identify the problems about which they would like to conduct their research.

(5) A research plan is made and a calendar of activities is prepared with the support of the Programme staff. Researchers visit their communities, interview authorities, service providers and other disabled persons to collect information about their selected problem.

They meet periodically to share all the information collected about a problem and reflect on their findings. Sometimes they invite other persons as guests to these meetings. They also think about and discuss the possible solutions and strategies to address those problems, including what they can do themselves, what can be done at community level and what can be done by the DPOs.

(6) The research may last at least a few months, more usually a year or even more. All their meeting reports including their findings, reflections and suggestions are reviewed by the programme staff, DPOs and TAG members, who can provide feedback, additional information and comments.

(7) As mentioned above, the process of enquiries, discussions and collective reflection on specific issues is similar to the principles of Freirian Praxis as used in Participatory Action Research (PAR). Often, during this process, the researchers along with other persons with disabilities in the communities and with DPOs, can initiate specific activities to respond to the needs they have identified.

(8) The whole process is accompanied by a reporter, a person who documents all the findings, discussions and follow-up activities.
Challenges of Freirian model of EDR

Over the past 10 years, I have been involved in 6 EDR projects in AIFO projects (2 in India, one each in Palestine, Italy, Liberia and Mongolia).

Challenges of EDR

Some of the key challenges of these researches in my experience have been the following:

Involving persons with specific disabilities as researchers: The EDR process promotes empowerment of disabled persons who are involved as researchers. However, not all persons benefit equally. Some persons, who are very shy and lack self-confidence, they require a lot of effort and support in the beginning and often other researchers get impatient with them and ask to replace them.

Persons with specific disabilities such as deaf persons, persons with cerebral palsy, persons with intellectual disabilities, persons with mental illness, and persons with leprosy, are usually excluded from EDR. Usually they are not so active in DPOs. Both DPO staff and Programme staff, may think that it will not be easy to work with them. Thus, they are often excluded and it requires persistent dialogue with DPOs, staff and other disabled persons to convince them about their inclusion.

Participation of women is another key issue. Even DPOs which have strong women leaders in top positions, are not able to convince communities to select disabled women as researchers. Even when selected, often men dominate the discussions and when women speak, the men may laugh or make comments. It requires continuous dialogue with researchers to make them aware about these biases.

Unrealistic expectations from the research: Some times DPOs and Programme staff have completely unrealistic expectations from the research. After 4-5 days of training, they think that researchers can do all kinds of qualitative and quantitative research. They may have little patience in supporting researchers who have difficulties in articulation or who are slow in understanding. Sometimes they expect specific kinds of written reports from researchers and can be too severe in their criticisms.

NGO programme staff can also be dominating and interfering in the research process, imposing their ideas on the researchers.

Limited Support of TAG experts: Most of the time, persons invited to become part of the Technical Advisory Group (TAG) of experts of an EDR are busy persons with a lot of responsibilities. Unless invited to a specific EDR activity to conduct training or provide advice, they may not have the time to read EDR reports and provide feedback and advice to the researchers. At the end, it is important to ensure that at least 1-2 persons with good research experience follow and support the whole EDR process, while the specific support from the remaining expert members of TAG needs to be negotiated.

Reporter: The person selected to write all the EDR reports is the interface between researchers and the rest of the Programme team and TAG members. Having a capable person in this role, can be the most important factor in ensuring success of EDR. The person should be articulate and computer literate.

We have tried with both kinds of persons in this role - person with disability as well as, a non-disabled person. Both can be a support or a hindrance to the process.

A disabled person as a reporter can be too anchored to his/her own disability experience and thus become an obstacle to free discussions in the group. Specific disabilities may limit his/her interaction with other researchers. Having fixed ideas about what should or should not be done about specific disability issues, can also block open discussions in the group.

A mature person who is self-secure and does not need to dominate others, who can raise question gently, and facilitate constructive and open discussions which are inclusive of all the researchers, is needed for this role.

Language issues: In rural areas where EDR is carried out, often persons with limited education can only speak and understand local dialects. Reporter and programme staff may not understand these languages. Even researchers who can understand these languages, may not be able to translate all the ideas and concepts in to the official language. Thus, often important information can be lost in the translation and may not be a part of the official research reports.

Community activities: Many discussions and at least part of the activities stimulated by the EDR process take place in communities and small groups, outside the formal meetings. Researchers may not understand the importance of bringing all this news and information to the reporter.

Difficulties Related to Formal meetings - these have pre-decided agendas and limited time. In these meetings, there may not be enough time to share general information about what is happening alongside the research process. Even when researchers bring this information, the reporter may not see its relevance.

Thus, many collateral developments related to EDR are ignored in the official reports.

Measuring Empowerment: A key goal of EDR is to promote empowerment of the disabled persons participating in the research. While there is a lot of anecdotal information about how the researchers and other disabled persons feel empowered in this process, there is no standardised way to measure the change in empowerment of individuals. While there are some attempts to measurement of empowerment (such as by the World Bank), these are not practical for use in the context of EDR.

Conclusions

The Freirian Model of EDR needs more reflection and understanding. If similar models are being tried anywhere in the world, it will be good to exchange information with them.

EDR can not answer all kinds of research questions. It can play an important role in understanding how local contexts and cultures, including lack of proper infrastructure and lack of services, influence the barriers faced by persons with disabilities in developing countries. These experiences of EDR can provide a richness of details about people’s lives and about the solutions they find to overcome their barriers, that may be difficult to get with any other research approach.

There is still a lot about the Freirian model of EDR, which needs to be understood and defined.

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