Thursday, March 31, 2011


Much hyped semifinal between India and Pakistan was finally over yesterday with India winning. The celebrations across the country made me wonder what was the achievement? They still have to win the finals on saturday against Sri Lanka.

Be that may, for many Indians and Pakis winning means a great boost to their national pride and honor. Ridiculous but true.

I have often felt Muslims in India are lucky. They are better off in a tolerant corrupt India than a begoted [honest]islamic country. It is reminder for all Indians that two of the last three crucial overs were bowled by two Indian Muslim boys, Munaf Patel and Zahir Khan.

Democracy in action for all to see!

Sunday, March 27, 2011

Earth [H] Our

Sent to me by my friend and one of the few young men who is doing his bit to keep the earth green. It is worth reading.

Earth (H)Our

At 8.30 pm on March 26th, as we turn off all electrical points in our homes for an hour, we could consider this an atonement, albiet a token one, for the economic runway that we have laid out for ourselves, riding on a blasphemous belief that energy – as much energy as we need - is a birthright.

Most people I know will switch off a light when they leave the room, yet this is hardly conservation; this is decency, protocol, the done thing, just as most people I know would say ‘Thank you’ when they were gifted a present. Conservation begins by questioning what could be done to change a lifestyle that is energy intensive and getting worse by the day.

A few months ago, a young journalist, Namrata Nandakumar, did a short study on electricity consumption in two urban spaces in Bangalore city. She first chose a slum which had ‘authorised’ access to electricity, a slum of three and a half thousand homes called Ullalu Upanagara, that houses about five times that number of people, during a post-monsoon month when there was no significant power cut. The monthly electricity bill for the entire colony was Rs. 2.38 lakhs. In contrast, Bangalore’s most popular mall, The Forum Mall, with a sanctioned load of 4 megawatts of electricity, had a monthly bill of about Rs. 85-90 lakhs (which included its expenditure on diesel for generators) for the energy it used with abandon, including the cooling of an enormous common areas around the day.

Recognise the sobering reality that energy is a finite resource currently in acute short supply in India. As the country’s GDP trots along, much more of it will be needed to supply basic energy needs to millions of our people as well as to meet the consumptive lifestyle of urban India. Energy comes at a cost, a cost well hidden from most of us who live in protected urban India and take planes when we travel : the costs, ecological, psychological, financial and otherwise, of displacement of people, damming of rivers, submergence of land and forests, pollution from thermal plants and carbon dioxide emissions and huge consumption of natural resources. Recognise that this is not a historical cost but a running one - for instance, the origins of the Maoist problem and the slums of urban India can be traced to our energy projects - and the true impact of the Mall’s consumption begins to emerge. Recognise, in addition, that the production of every litre of diesel needs 9,200 litres of water and 2-3% of the diesel that is imported into India is consumed in its own transportation to the consumer.

Yet, none of us would seem particularly perturbed with these numbers, ascribing them to a convenient rung on the ladder of development, for we empathise, not with the slum, but with the mall. It is a lifestyle that, though recent and foreign, is not negotiable. The biggest issue, of course, is that we – literate, well-read, well-meaning, intelligent as we are - do not connect the dots. We cannot, often do not, wish to see the impact of our actions on others. Let us then not blame the Americans for the climate mess we are in. Given an option, we have grabbed the ‘pollute’ lever ourselves for the short term gains that accrue from glamorous living.

I have in front of me, two recent articles that are very recent, yet hardly new in content. The first speaks of the protests last month against the East Coast Energy coal-fired power plant in Srikakulam district in Andhra, during which two people lost their lives, lives that were worth much more than any power plant could possibly match. This plant coming up next to a ecologically fragile wetland has, over the last couple of years, damaged the area and put many fishermen and farmers’ livelihoods in peril as the wetland is excavated and filled up in haste. The police were there, of course, to help push this private project through. This incident was merely a repeat: on July 14, 2010, in Sompeta, where the Nagarjuna Construction Company is building a thermal plant on a wetland, three persons were killed in clashes with the police.

The second article concerns a different source of energy that threatens a different species. If you make your way into the Athirapilly-Vazhachal forests of Kerala, as I have done – dense, wet deciduous forests of breathtaking beauty and surprise – you occasionally hear a loud, pitched call, a distinctive ‘tock-tock-tock’ , or sometimes a heavy whooshing sound. Look up or around (if you are by a ridge) and you might see the Great Indian Hornbill take to the air, the most beautiful, graceful, charismatic, even-tempered bird that has ever been. It is a bird that might see its habitat destroyed with a hydroelectric project proposed by the Kerala State Electricity Board that will generate a measly 160 megawatts, for the forty Forum-Mall-look-alikes that will dot the state to sell the resident Malayalee’s sole fetish: gold. The Hornbill, stunning as it is, is merely a representative species of the priceless biodiversity we stand to lose at Athirapilly, a portion of which is not even known to science as more discoveries enhance our sense of wonder at the mechanics of creation.

To set the record straight, the KSEB is hardly the first State Electricity Board to consider habitat of little use except for submergence, yet it was a pioneer in the destruction effort, with a plan made forty years ago to submerge the Silent Valley. It required the determined effort of Dr. Salim Ali and Mrs. Indira Gandhi to scuttle the project.

The destruction of forests, and the biodiversity within it, is a horrendous cost to pay for our lifestyle, yet it is a cost that few of us understand, even as the decision makers do the hypocritical act of planting the odd sapling to mark an Earth Day or a Wildlife Week. Much before additional power plants of any kind – thermal, nuclear or hydro – are planned, there is need, indeed a pressing, vital need, to use a system of incentives and disincentives to get the energy addicts (that’s us) to reduce our need for the fix. Yet, I have little faith in the Government’s ability to promote a culture of reduction and thrift and a lot more conviction in your ability to reason and conclude.

In my few years in conservation, never have I felt this alarmed at the speed of the consumption gravy-train. On March 26th, therefore, I have a request to make : please switch your lights, air coolers, water heaters and all else off, for just an hour. This, by itself, will make little difference, yet it will hopefully provide the darkness needed for a few moments of solitude.

In those moments, do think of just how you could become part of the solution, just how you could change the way you live your life to reduce, dramatically lessen, the need for energy. I repeat, target, not a 5% drop in consumption but, a 50% reduction in your energy demand. …for unless we press the brake now, the energy gravy train will run over the person on the railway track.

That person is you. And the time to heal the Earth is Now.

Warm regards,


Earth hour

I was out driving a friend home during the earth hour. I had to despite the fact using the vehicle too is against the green movement. I was pleasantly surprised with the response from the citizens of the city.

Most had switched off the lights and the vehicles were less on the roads. This awareness should be there all the time and at all levels. More importantly at the levels of politicians and beurocrats as these are the decision makers.

My city is being slowly and steadily being destroyed in the name of development.More roads are being built or widenied and more vehicles are allowed on the roads. Many busy roads have no place for the pedestrian and the cyclist. Moving from one part of the city to another has become a night mare. More and more trees are felled to make way for roads in the name of development. Once, the city had hundreds of lakes which were interconnected and water flowed from west to east.Now many of these are filled up and developed. What is this development? Building more and more apartments and housing colonies.

The city's population has quadrypled in less than 15 years. The water needs of the city are met with the crazy scheme of pumping water up a gradient of 2000 ft from a distance of 100kms.Where is the power coming from? build more hidel and nuclear powerplants, inundate verdat forest and agri land and invite disaster?

Gandhi, nearly a century ago had anticipated all this. He advocated minimum consumption of resources as the key to life. Is any one listening? Today's developers are taking away resources of tomorrow's generation. Who is worried?

Mr Gandhi must be turning in his grave!

Saturday, March 26, 2011

Chasing the ESR

We doctors order investigations when we are stumped as to what is wrong with the patient or some times to know the effect of treatment. Added to these, we also order teats to assess fitness levels. This last phenomenon which was exceptional when I began my career has now become routine. So common it is that patients themselves go to the lab and get tests done and then see us. Most often it is a sheer waste of money but occasionally it results in early diagnosis and effective management.

When tests are ordered a common one among them is called the ESR. This stands for erythrocyte sedimentation rate. In simple language it means speed with which the red cells of the blood drop when a column of blood is suspended in a glass tube. This simple screening test is very nonspecific. It tells us that there is something wrong but does not tell us where and what is wrong. A friend of mine once said you sneeze hard couple of times and then measure the ESR and sure it will be up.

Red cells are in large numbers compared to white cells. Their main purpose is to carry oxygen to the tissues and normally they circulate without clumping and when suspended they drop down ever so slowly. In disease conditions the rate of this fall is rapid. The higher the fall more serious is the disease. We accumulate willy nilly, lot of unwanted material in the blood during the course of our lives. These include among others bacterial and viral antigens against which the immune system produces antibodies, particulate materials which freely flow in our blood much in excess of the ability of our innate cleaning systems to scavenge. Some of these stick to the surface of the cells and make them not only heavy but also get them to stick to one another. Thus the cells which were once clean now become dirt laden and heavy and thus fall faster in suspension and the ESR goes up. In acute infections and in malignancies, the phenomenon is marked. And very high ESR levels are always worrying to the attending doctor.

Mrs. Y is a sixty year old woman and a true party animal. When she was with a group of friends, one of them told her that she was looking pale. Everyone looks pale in the artificial light and Mrs. Y did not attach any importance to the remark. Few days later at another party another friend remarked,’ what is the matter with you? You are looking very pale’. Remarks of similar nature on two successive days had her worried.

She took the decision to do the tests. Had she come to me I probably would have examined her and may and more likely not have got any tests done. She went to a well known lab and told at the reception to tests for her looking pale. Most labs are privately owned and clients like Mrs. Y are like a new lode of gold for them. All tests including the scans of her chest and abdomen were done. Here is something interesting. It is not difficult to find some trivial abnormality in most people and as they say half in jest, when you see a tail sticking out of a hole it is sometimes best not to pull it out, you don’t know whether you pull out a cat or leopard. The labs too have a funny way of reporting here. They put an asterisk against the slightest abnormality that is found or a value which even slightly abnormal. In madam Y’s case there were many such asterisks!

Thoroughly frightened, Mrs. Y landed in my clinic with a whole wad of papers. ‘I am very sick’ she said by the way of opening remark. She looked very fit and I said so. ‘No, no, you see these reports and then you will change your opinion’ she said. If she is insisting to be very sick, I felt I should first examine her before going through her papers. She agreed and a ten minutes physical found her in a fit condition with her basic parameters being normal. Now came the time to see her lab reports and scan reports and I could see her becoming visibly anxious. Almost all her reports including the ones marked with an asterisk were normal. There was however one major abnormality. Her ESR was very high. Normally in her age group it should not exceed 20mm of fall in an hour and in her it was 80.

This was indeed a surprise and a cause for worry. Surprise because she was fit and I found nothing which would explain this high ESR. In the absence of infection the only other cause would be occult [hidden cancer]. In women the most likely place is the breast where small tumors could easily missed. I felt her breasts once again. I could find no mass small or big. I found among her papers recent tests to exclude cervical [uterus] and ovarian cancer. Then where is it? Could this be in her blood forming bone marrow? Could this be in her colon? Lungs?

I had no option but to get a whole lot of expensive tests done. May be a better option would be to send her to an institution [an unsettling thought]. My brain was buzzing with all sorts of thoughts and idly I was sheafing through her papers and saw her liver function tests. There was a marginal increase in the globulin fraction of her blood protein. Globulins are very important componets of our immune system and special cells called plasma cells make these.

Here was a possible clue. Without telling her what I was thinking but all the same reassuring her, I ordered a test called serum protein electrophoresis in which the various fractions of blood proteins are studied, a non invasive test. She came back two days later with the report. She had a raised level of one particular fraction of her gamma globulin. I, at last, had the diagnosis. She has monoclonal gammopathy of uncertain cause. This condition is due to excessive production of gamma globulin of one variety by one clone of cells. This excess protein adheres to the surface of the red cells and thus making them heavy and drop faster in suspension. Monoclonal gammopathy is premalignant condition and in time a percentage of them go into a type of cancer called multiple myeloma. No one knows who will develop into this serious condition and who will not. I have had several patients who have carried MGUS [monoclonal gammopathy of uncertain significance] to their grave without suffering Multiple Myeloma.
I painted the picture highlighting the positive aspects. That was ten years ago. She is now seventy. The other day she had come for the usual follow up with her reports. They were all normal and she too will hopefully carry this to her grave without going into cancer when ever her time comes to go.

Wednesday, March 23, 2011

In search of the stink

They first noticed the foul smell two weeks ago while watching television more or less at the same time, the wife first and then the husband. They thought the smell is because of a dead mouse that was seen inside the home couple of days back. They took the house apart looking for the dead mouse but to no avail. Then couple of days later the husband told the wife that he noticed the same smell in his office. They thought justifiably that he was imagining the smell!

Next day too he said the same and confirmed that it was no imagination as his secretary too smelt the stinky waft. How can the same smell be both in the office as well as home?
Realization came at last. The smell was coming from the body of the man! Wife found that it was from his navel and on close inspection she found a whitish substance in the depth of his belly button. She made him wash it thoroughly; still the smell remained though the whitish material was no longer there.

This was the time they thought it to be serious enough to seek medical advice and came to see me.

The stink was obvious even before she told me its origin. He had a navel which was deep and well hidden in the fat fold of his paunch. I could with difficulty, [I used an old fashioned nasal speculum] to separate the overhanging skin folds. There I could see something glistening! It was quite easy to pull it out with a forceps. An inch and a half of cone shaped hard rubbish was pulled out. The cavity was washed and sterilized with iodine.

That was the end of foul smell. The cone contained debris, shed skin, secretions all of which had joined together to produce this foul cone!

I asked the couple if they wanted to take it home as a memorable memento. They vehemently refused!

I then dumped it in the toilet bowl and flushed it to make sure it went for ever.