"Eliminating" Infections In India

In today's FirstPost, an online newspaper from India, there is a cover story on Neglected Tropical Diseases (NTDs) by Kalikesh Singh Deo, "a member of the Biju Janata Dal party. He is the Convenor of the National Coalition on Neglected Tropical Diseases and Malaria".

I have some concerns about the use of term "elimination" for reducing the number of certain diseases like Kala Azar and Lymphatic Filariasis, under the guidance of the World Health Organisation (WHO). I hope that bodies advising the Government of India would have discussions with stakeholders to ensure a reduction in the negative fall-out from the use of such terminology.

Let me explain why I think that using terms like "elimination" in such campaigns is a double-edged sword. (The image below presents some ASHA workers from Maharashtra, India - all public health programmes reach people through these front-line workers in India - without them no campaign or programme can work).

WHO's Definitions

In 2016, WHO produced a document about the use of terms like "elimination". According to this document, the following terms have following meanings for the infectious diseases (page 3):

Control: Reducing the number of cases of a disease

Elimination: Reducing a disease to zero new cases (incidence) in a country or an area

Eradication: The causative organism has been eradicated from nature and laboratories so that it can not cause any new infection

In addition, there is a 4th definition, which is called "Elimination as a Public Health Problem" - this means reducing the numbers of cases of a disease so it is no longer a problem for the health services.

Advantages of Using terms like Elimination

In his article, K.S. Deo explains: "By December 2023, the Government of India plans to reduce kala-azar cases to less than one per 10,000 people at the block level and, by 2030, to eliminate haati pao as well."

Reading the strategy and such explanations, the readers feel that the problem is going to be solved. In this article, he does not use the term "elimination as a public health problem" because he understands that this won't make much sense to ordinary readers.

There are different advantages of using words like "elimination", including getting more resources from the Government and greater commitment from health services and health personnel.

There are real gains on the ground as well. For example, Deo writes: "10 February 2023, India will conduct Mass Drug Administration (MDA) rounds in Mission Mode in 10 affected states". This means that a large number of people will receive medicines to treat and to prevent new infections.

Disadvantages of Using Terms like Elimination

The first time the term "elimination as a public health problem" was used was in 1991, when WHO had launched its Leprosy Elimination Strategy (LES) - to reduce leprosy by the year 2000. At that time I was a member of the the medical commission of the International Leprosy Associations Federation (ILEP) and many of our members had concerns that people will not understand the term "elimination as a public health problem" and will think that the disease has been eliminated, they will believe that it no longer requires resources and services.

The LES had a huge impact in India. In most of north India very few public health services were reaching leprosy patients and most of them were being treated by older lesser-effective medicines. For example, due to LES, by 1998 even states like Bihar and UP managed to provide almost 100% coverage with newer and more effective anti-leprosy drugs to all those who needed them.

The problem came after India had reached the LES goal (in 2005). Many states reduced their support for leprosy services. It was not only decision-makers or general population who had thought that leprosy will be actually eliminated and there won't be any more new cases, even doctors and public health specialists believed it.

For example, 4 years ago, Dr Madhukar Pai, director of McGill International TB Centre and a well-known and influential public health specialist based in Canada, in his article "Failures of Public Health" wrote the following:

In 2005, India declared leprosy to be eliminated and scaled-back on its leprosy programmes. Today, according to WHO, India harbors 60 percent of the world’s cases, with more than 100,000 new diagnoses each year

I can tell many anecdotes of people coming up to me with questions about why governments had declared "leprosy is eliminated" when they still had the disease. I have even seen a sociology thesis from a country in Africa, which had a theory about the LES declaration and a national conspiracy to marginalise the poor persons for the benefit of the rich.

Conclusions

I think that it will be good if Mr. K.S. Deo and his team will bring together different stakeholders, including representatives of leprosy-organisations to find ways which allow us to use the term "elimination" for the advantages it provides and at the same time, find alternate ways to mitigate the damage caused people's expectations that these diseases will disappear.

For example, it might be important to use some other word and not use the word "elimination" in the local language translations about the campaigns.

18 years after Eliminating Leprosy as a public health problem in India, it continues to be a public health problem and is a part of NTD strategy about which Deo has written. LES had an impact, the number of new cases of leprosy in India has been halved (partly this may be due to covid-related reduction in services, so that many new cases were not detected) but the disease is still there and it requires services. It is crucial to avoid mistakes of the past.

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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.

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

Surgery in Ancient India & Ganesha

Ganesha, the anthropomorphic divinity with the elephant's head, is one of the most loved God-figures in Hinduism. Some persons have claimed that the Ganesha story is a sign of knowledge about advanced surgical skills in ancient India and that those ancient surgeons knew how to transplant an animal head on a human body. While such claims are laughable, I do believe that there can be some links between the myth of Ganesha and the knowledge of surgery in ancient India.

This post is about surgery in ancient India and how it could have given birth to the Ganesha myth.

The Ganesha Story

I love the figure of Ganesha. For me, it symbolises the omnipresent links between humans and different aspects of nature, which permeate different aspects of Hinduism. They teach us to look with respect at every aspect of nature - from the microscopic bacteria and ants to animals and plants, and even the snow covered mountains. If you have seen individuals in India offering flour or grains to ants and snakes and monks going around with a mask for their mouths, you can understand the vitality of this link between Indic religions and nature.

In the Indian mythology, Ganesha is the son of Shiva and Parvati, born while his father is away. Many years later, one day Shiva comes back home and is stopped by Ganesha, who does not know him and is guarding the door because his mother is taking bath. Angry, Shiva cuts his head. Later when he realises his mistake, it is too late, some animal has eaten his son's head. So Shiva sends his men to look for another head, and his men bring back the head of a baby elephant which is put on the boy's torso. This is how Ganesha's elephant head is explained in the mythology.

Transplanting An Animal Head

Some persons take the Ganesha story literally and believe that ancient Indians knew how to transplant an animal head on that of a human being. Even if it was possible to sew and transplant an animal head on a human body, and even if it was possible to avoid the inter-species transplant rejection, no real elephant's head, not even a baby elephant head, can fit the human body, unless we are talking of elephant-sized giant men from Gulliver's Travels. Thus, this story is only a story.

However, ancient Indians did develop surgical skills almost 2000 years ago, which were probably unique in the world at that time. Some of those techniques are still used in modern surgery. I wonder if the story of one such surgical operation could have given birth to the Ganesha myth. Let me explain.

Surgery in Ancient India

Mentions of surgery are found from Rigveda onwards in different texts of Hinduism and some of the well known ancient surgeons mentioned in these texts include Ashwini Kumaras, Chavana, Dhanvantari, Atereya Agnivesh and Sushruta. Sushruta from 600 BCE is called the father of Indian surgery, and his book known as Sushruta Samhita contains indications regarding cosmetic, plastic, and dental surgery ("Sandhan Karma").

Dr. Vibha Singh in an article published in the Journal of Maxillofacial Surgery in 2017 had written about it:

The ancient surgical science was known as Shalya Tantra. Shalya means broken arrow or a sharp part of a weapon and Tantra means maneuver. Shalya Tantra embraces all processes, aiming at the removal of factors responsible for producing pain or misery to the body or mind. Since warfare was common then, the injuries sustained led to the development of surgery as refined scientific skill ...Complicated surgeries such as cesarean, cataract, artificial limb, fractures, urinary stones plastic surgery, and procedures including per- and post-operative treatment along with complications written in Sushrutaa Samhita, which is considered to be a part of Atharva Veda, are surprisingly applicable even in the present time ...Even today, rhinoplasty described by Shushruta in 600 BC is referred to as the Indian flap and he is known as the originator of plastic surgery. Besides trauma involving general surgery, Sushruta gives an in-depth account and a description of the treatment of 12 varieties of fracture and six types of dislocation. This continues to spellbind orthopedic surgeons even today. He mentions the principles of traction, manipulation, apposition, stabilization, and postoperative physiotherapy ...

Knowledge about surgery travelled from India to the Arab World in the 8th CE and then to Europe. Prof. Thamburaj in his book Textbook of Contemporary Neurosurgery wrote that Sushruta Samhita was translated into Arabic as 'Kitab Shah Shun al–Hindi' and 'Kitab–I–Susurud'. There were Latin and German translations of this text in early 19th century but I think that there must have other translations of this text in the past and the knowledge about the Indian techniques had reached Europe much earlier.

Dr Frank McDowell in his 1977 book on Plastic Surgery had written: "Through all of Sushruta's flowery language, incantations and irrelevancies, there shines the unmistakable picture of a great surgeon. Undaunted by his failures and unimpressed by his successes, he sought the truth unceasingly and passed it on to those who followed. He attacked diseases and deformities definatively, with reasoned and logical methods. When the path did not exist, he made one."

The Skin Grafting Technique from India

Skin grafts are needed when the skin is destroyed, such as in burn and crush injuries. Broadly, there are two kinds of skin grafts - a partial skin graft and a full skin graft. The full skin grafts were described in Sushruta Samhita.

When wounds are big or deeper, and a thin strip of skin is not enough, we need a graft with the full depth of the skin and underlying tissues including blood vessels and nerves. For this, the surgeons cut a piece of full skin tissue from three sides, usually from abdomen, arms or thighs, while making sure that it remains attached on the 4th side to the original part of the body, from where it can continue to receive blood. This skin flap is used to cover the wound. This means, the surgeon needs to bring together the wound to the body part which is going to donate the skin, and they need to stay together for some weeks, till the grafted skin starts getting blood from the underlying tissues. Once the grafted skin is well fixed to the new area, the flap can be cut at the base and two parts can be separated.

The Origins of Ganesha Myth

Is it possible that the Ganesha myth started from a surgery in ancient India? Lets suppose that there was a young boy who was a priest at a Shiva or Shakti temple and he was attacked by someone who wanted to loot the temple. He was able to protect the temple but his nose was cut during the fight. He was operated by a surgeon who took a full skin flap from his upper arm and used it to construct a nose for him. After the operation, he was forced to keep his arm close to his face with his forearm hanging in front of his face like an elephant's trunk for a few weeks or months. Suppose, someone called him the boy with the elephant's head and over time, it gave rise to the Ganesha story?

Hinudism has a strong traditions of an oral culture, where old stories are made into songs, adapted to the local context and passed across generations. Over centuries, such a story could have become the Ganesha's mythical story and the sages incorporated that story in a sacred book, explaining him to be Shiva and Parvati's son.

Conclusions

Hinduism is a living tradition that has roots going back to antiquity. This living tradition is incredibly complex, where each story has innumerable versions, and some of them can be contradictory. Over centuries, stories which can have deep metaphorical meanings become widespread and find a place in one of its sacred texts.

My considerations about the origins of the Ganesha story are just speculations and can't be taken as truth. They build a story around the surgical skills about skin-grafting in ancient India. There is no way to prove this story and any way, that is not the purpose of this post.

Additional notes about this surgery in India are given below:  I think that this additional information is important because it shows that Ayurvedic operations based on the ancient techniques described in old books of Sushruta Samhita and Charaka Samhita, were being practiced in India in 18th century and were taken to west much more recently than has been claimed.

Additional Notes, 11 August 2020 (From @trueindologyorg on Instagram):

The above is the picture of world's first known modern plastic surgery. It is also the picture of world's first known modern nose job. It was performed by a traditional Indian surgeon named Kumar. The person in this picture was known as Cowasji. He was a Maratha bullock driver. He had been imprisoned by Tipu Sultan and his nose was cut off in prison. His nose was later restored by a traditional Surgeon named Kumar using "ancient Indian methods" in 1794 CE.

A Britisher named Lucas observed in action the traditional Indian surgery of Cowasji and documented every detail of this operation. This picture was a British portrait of Cowasji AFTER Rhinoplasty (c. 1795 CE). At that time, the Europeans lacked the scientific knowledge and expertise needed to perform plastic surgery. They were greatly intrigued by this method and found it was commonly performed in India. They also noted how Susruta Samhita described this procedure of Rhinoplasty in detail. These details were then accessed by a scientist named Joseph Constantine Carpue. Using these techniques, he performed world's "first" modern Rhinoplasty 20 years later.

Joseph Constantine Carpue is widely known as the father of Plastic Surgery. But in his book "An account of two successful operations" , he acknowledges that it was performed by "Indians from time immemorial". He learnt it through his friends who "copied from Hindoo practitioners" in his own words. Nasal reconstructions had been practiced as a relatively routine procedure in India for centuries. The procedures are described in two well-known early Indian medical works like the Suśruta Samhitā. By the nineteenth century, the technique had been handed down through families.

Traditional Indian sources recommend that Kumbhakaras (potters) perform the surgery owing to their skill. They performed it till 18th century. Source: "An account of two successful operations " by Joseph Constantine Carpue. Image source: https://blogs.bl.uk/science/2016/10/britains- first-nose-job.html

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#surgery #medicine #ayurveda #ancientindia #ganesha #hinduism

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

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

Is there still leprosy in India?

Recently in a Twitter debate, a message said that leprosy was eliminated in India in 2005. Then another person asked, “So it means we have no leprosy in India?” The answer was that India still has leprosy but it is below the WHO cut-off level, implying that it was no longer an important issue.

I intervened at this point, specifying that every year, India has about 130,000 new cases of leprosy and I feel that it is still an important issue for public health in India.

I can understand why people get confused. If it is true that leprosy was eliminated in India in 2005, then how can we still get 130,000 new cases of leprosy every year?

The answer is that in this case, WHO has a specific definition of “elimination” – it refers to persons registered for treatment for leprosy at the end of a year. If number of persons receiving treatment at the end of year is less than 1 per 10,000 population, according to this definition, it means that the country has “eliminated leprosy”. That is how, India has eliminated leprosy even if we get 1.3 lakh new cases every year.

The old definition of "leprosy elimination" when its prevalence goes below 1 per 10,000 population is an old definition and is no longer useful. However, in public health, old definitions can continue to have their own life and continue to create new confusions! To understand, how we came to this situation, we need to rewind and go back to 1989.

New treatment of leprosy

A new treatment of leprosy was proposed in the early 1982 by the World Health Organization (WHO). This treatment included 3 drugs – Dapsone, Clofazimine and Rifampicine. Being a combination of drugs, the new treatment was called Multi-Drug Treatment or MDT. Before MDT, people needed to take leprosy treatment for decades or even all their life without ever getting cured of the infection. With MDT, within 1-3 years, people could be completely cured of the infection.

Though MDT was such an effective treatment, hospitals and doctors treating leprosy were slow to adopt it. It was thought that doctors needed to carry out some tests before starting MDT and then directly supervise people receiving this treatment. Since in poor countries, laboratories for doing the tests and doctors to supervise the treatment were lacking, most people with leprosy were not given the new drugs, even if they were so much better compared to the old treatments.

In 1989, WHO had organized a meeting in Brazaville in Congo to talk about leprosy and MDT. I was there in this meeting. I don’t remember much about that meeting except for the dismay of many participants that in spite of so much efforts, in most countries less than 10% of the leprosy cases were being treated with MDT. The question was what to do to ensure that everyone could be treated with the new drugs?

Elimination strategy of WHO

In 1991, leprosy team of WHO came out with a solution to strengthen the use of MDT in treating leprosy patients - it was called the New Strategy for Leprosy Elimination. To promote the treatment with MDT, it asked countries to focus on bringing down the leprosy prevalence (by decreasing the number of persons being registered for treatment at the end of year) by the year 2000. As persons completed their treatment, their names could be removed and the prevalence would decrease. The idea was to ignore the number of new cases but to focus on giving them treatment and removing their names from the leprosy registers.

The key to bringing down the prevalence of leprosy was to treat people with MDT. To facilitate it, the treatment duration was decreased and diagnosis of leprosy was simplified – you didn’t need to do any tests for starting MDT and doctors were not needed to supervise the medicine-taking by the patients.

In India, new MDT programmes were started mainly in south India around the last part of 1980s and early 1990s. Only towards the end of 1990s, these MDT programmes reached north India. Only around 1998-99, India managed to treat all its new leprosy patients with MDT. Thus, India was not able to reach the elimination goal of WHO in 2000, but it managed to achieve it in 2005.

There was another idea underlying the elimination strategy – WHO experts thought that if we could treat all infected persons in a community, then the level of infection will drop, slowly the disease transmission will automatically decrease and new cases of leprosy will also come down over a period of time.

Leprosy elimination strategy had many positive effects – it managed to increase the MDT coverage to 100% - all leprosy patients started to be treated with MDT. However, it also had a negative effect – when countries reached the elimination goal, they thought that their leprosy problem was finished and often they stopped paying attention to it.

Leprosy in India today

As mentioned earlier, India still has about 130,000 new cases of leprosy every year. After India reached the “elimination” in 2005, we stopped routine looking for new cases of leprosy in the communities. Instead, now we expect them to report themselves to a Primary Health Care (PHC) centres and come for diagnosis and treatment. The Government is supposed to carry out mass awareness programmes so that persons suspected of having the disease can go to PHCs for a check-up. However, persons in villages are not always aware of the different changes and misconceptions about leprosy are common. In fact, many leprosy surveys carried out in India over the past decade, have shown that actual number of persons with leprosy in India is much higher than the official reports.

Over the past 10 years (2007 to 2017), the official number of new cases of leprosy in India has been relatively stable – in 2007, we had around 137,000 new cases, while in 2016 the number was around 134,000. Thus, so far the idea that if we treat everyone, the number of new cases will decrease automatically, has not turned out to be true. Perhaps, there are other factors contributing to this slow decline in number of new cases - for example, some doctors believe that highly infectious cases (LL cases) need longer treatment otherwise they might act as source of new leprosy infections in the communities. Some new strategies, such as "single dose Rifampicine" to persons at risk for prevention of leprosy are being tried.

Is talking About Leprosy Elimination Useful Today?

I feel that today it makes no sense to talk about “elimination of leprosy” in the way this goal was defined in 1991. We want people to come to PHC and get treatment for leprosy and at the same time we say that leprosy has been eliminated. It means that we are giving two contradictory messages to people, which creates confusion.

Over the past 3 decades, I have visited leprosy programmes in a large number of countries and seen the impact of MDT - I have seen the leprosy situation change in front of me. Today, most new cases of leprosy have few signs of the disease. If they take treatment, they get completely cured without any disfigurement. Thus, leprosy can be like any other curable disease. However, the situation is worse in far-away areas and even urban peripheries because of misconceptions and lack of awareness. People who come late for treatment, many of them end up with needless disfigurement.

This is also true in India, where persons living in isolated areas do not get early access to leprosy treatment.

All countries where leprosy is endemic are facing this situation. Many decision-makers and people think that leprosy has been defeated but in reality, we still have a significant problem and need good leprosy programmes to identify all the new cases and to treat them early so that they do not develop any disabilities due to the disease.

Conclusions

Today leprosy is easily treatable. It is no longer a dreaded disease even if many persons carry prejudices against persons with leprosy because of lack of knowledge.

Many countries including India, which have “eliminated leprosy”, continue to have significant number of new cases.

(1) I believe that we need to stop talking of “leprosy elimination” - today, it makes no sense. It only creates confusion in the mind of both health workers and communities.

(2) Decision makers need to accept that we have and will continue to have a significant number of leprosy cases in India in the near future, who will need to get treatment and other services. In fact, the current strategies of controlling leprosy need to be reviewed to focus on decreasing the number of new cases of leprosy and to reduce the number of persons who get disabilities due to leprosy. Fixing unrealistic targets to reduce leprosy is not the best way to go about it - it penalises hardworking and good leprosy workers, who are seen as a problem if they keep on finding a large number of new cases.

Note: The author was associated with ILEP (International Anti-Leprosy Federation) for a number of years as a member of the medical commission and as its past president. He has conducted evaluation of leprosy programmes in different countries of Asia, Africa and South America. He is one of the organisers of International Leprosy Mailing list and associated with IDEA, the international organisation bringing together persons affected with leprosy.

The images used in this post are from an evaluation of leprosy programme in some districts of Maharashtra in 2016.

*****

#leprosyinindia #leprosy #ashaworkers #primaryhealthcare #eliminationofleprosy 

Doctors and Alternate Sexualities

Note: I had written this article for the newsletter of Xukia, an organisation based in Guwahati, fighting for the rights of LGBTQI (Lesbian, Gay, Bisexual, Transgender, Queer and Intersexual) persons in the north-east of India. The images used in this article are from LGBTQI Pride Parades organized by Xukia and held in Guwahati in 2015 and 2016.

***

It was around 1973-74. I was a medical student. One evening, a close friend from my school days had hesitatingly asked me for advice. He felt attraction towards a male classmate in the university and wanted to know if this meant that he was gay. Probably he had thought that because I was studying medicine, I must know something about it.

I was not sure how to answer him. Yet, I was pleased that he had enough confidence in me to raise that question. I don’t think that it was, and I don’t think that it is, easy to discuss doubts about your sexuality with your close friends.

Till that time, the subject of sexualities had never been raised in our medical studies. In our anatomy class, when he had come to the chapters on sexual organs, our male professor had told us with a knowing smile that we could read those chapters ourselves. I used to think that it will be taught in the final year. I wouldn’t have believed at that time that at undergraduate level, medical students were not taught any thing related to sex, sexuality or genitals.

And, I don’t know how much of it has changed today. Perhaps young doctors can add about their own learnings on sex and sexualities in the medical colleges in India now.

It was a time when many of us went to work after the medical degree, rather than going for a specialisation. So our education system was turning out doctors, who were going to work, and who had never been taught anything about sexuality.

During our clinical studies, we had studied about the health conditions linked to the genital organs, especially sexually transmitted diseases, those that require surgery and those related to child-birth. And that was the end of our sexuality knowledge. Our medical education was linking sexuality exclusively to the ideas of disease conditions, rather than to ideas of pleasure and self-fulfilment.

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“So what is the opinion of the doctor about it? Is it normal?” Similar questions are common in a variety of situations. When people are not sure about something related to the human body, asking the opinion of the doctors seems like a logical solution.

Rarely people ask themselves if the doctors have the knowledge and training to answer those questions properly. It is difficult to think that doctors, like most other persons in the society, carry the usual prejudices of the society in which they live.

There is limited research in India on the issues of sexualities. Often the research is carried out under the aegis of psychiatry departments, leading to the impression that sexuality is related to psychiatric disturbances.

I could not find any research on attitudes of Indian doctors about alternate sexualities. However, from colleagues, I have heard stories of doctors refusing to see and to treat transgender persons or being rude to them.

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What are the opinions of Indian doctors about LGBTQ issues?

After the Supreme Court judgement on 11 December 2013, that reinstated section 377 of Indian Penal Code, on 27th December 2013 the Indian Medical Association (IMA) passed a resolution that “homosexuality is a variation of sexual orientation and not a disease”. However, many members of IMA did not agree with this official position.

On 19 January 2014, an ex-president of Indian Psychiatric Society (IPS) said that in India, talking of sex was unnatural and that homosexuals had brought these discussions out on the streets, implying that homosexuals were unnatural. Some days later, on 3 February 2014, the general secretary of IPS said that “Homosexuality is a grey area, entailing confusion and complexity, and black and white comments can't be made on it”. The above statements made by psychiatrists, who are supposed to have greater understanding about sexualities, did provoke some debates. Thus, On 7 February 2014, IPS was forced to issue a statement that “there is no evidence to substantiate that homosexuality is an illness or a disease”.

A recent newspaper story dated 26 July 2015 talked about a group of psychiatrists in Delhi who considered homosexuality as “a condition similar to bipolar disorders and schizophrenia”, to be treated by “conversion therapy” based on electro-shocks. This story provided details of interviews with many doctors.

One doctor claimed to have “helped” more than a thousand persons in “treating” homosexuality and usually charged 1.1 lakh Rs as a “complete package for treatment”. Another clinic claimed to “cure homosexuality” in one month for “only” 2,100 Rs. One doctor blamed the “excess of female hormones in male bodies” for homosexuality, while another talked of a “recessive homosexuality gene”.

Such pseudo-scientific talks, not based on any scientific-evidence, feed on the common prejudices among people. Since doctors and even more so, specialists like psychiatrists, are seen as authority figures, such claims and such services, serve to perpetuate and strengthen stereotypes and prejudices in the society.

Thus, even when official medical bodies make the “right” statements, individual doctors often continue to hold-on to their ideas that do not agree with the official positions.

These newspaper stories were about doctors in Delhi, but are doctors in other cities any better? What about similar doctors and clinics in the North-east? Probably the situation will not be so different.

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So what should persons do when they want an advice about a sexuality issue from a health professional?

There are many occasions when LGBTQ persons and their families need sensitive and sensible advice from professionals who understand their worlds and their specific needs – such as, when young people are not sure about their orientation or gender, when persons wish to undertake hormonal or surgical treatment for gender reassignment, and when persons want to have families and think of surrogate pregnancy or artificial insemination.

Today a lot of information is available on internet. However, it is not always easy to judge the reliability of this information. It may be too much and sometimes, contradictory. Thus coming to a decision may not be easy and some guidance may be needed. However, I feel that the greatest advantage of internet based information relates to sharing of personal life stories and experiences, and creating peer support groups.

One answer for LGBTQ groups can be to start working on creating a database of responsible and sensitive health professionals in their cities. For example, a group of persons have started a crowd-sourcing work on identifying “Gynaecologists whom we can trust” (#GynaecsWeCanTrust), that provides information in different languages about reliable gynaecologists in different Indian cities.

Some time ago I had visited the office of an Association of transgender persons in Bologna (Italy) called MIT. They were able to convince the local government on the need of having access to experienced psychologists and health professionals. Thus, in their office, the local government had agreed to provide them with professionals, to be available for consultation a few times in a month. Though initially the professionals had limited knowledge and skills about issues related to transgender persons, with time, they were able to gain both.

Hoping for a support from the Government on this issue in India may not be realistic in the short term, but perhaps similar solutions can be explored by GLBT Rights organisations and groups locally with some professionals who have an understanding of these issues.

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I want to conclude this article with a few images from the LGBTQI Pride Parades held in Guwahati (Assam, India) in 2015-16.

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