It’s been a year – of great fun and learning.Medical ruminations turns one today! I have benefited immensely from your words of wisdom.
Just wanted to take the time out to say a Big Thank you 🙂
It’s been a year – of great fun and learning.Medical ruminations turns one today! I have benefited immensely from your words of wisdom.
Just wanted to take the time out to say a Big Thank you 🙂
Sometimes your moment of epiphany comes in the most unlikely of places. And things are never the same again.
It was November 2012. I had just gotten married and booked tickets to Andamans. On day 2 , we had gone to the Cellular Jail. Little did I know that the night would mark a tectonic shift in my world view. They had arranged a light and sound show to show the tourists about the struggles of countless men incarcerated there during India’s darkest years. The sheer impossibility of escape and the brutal conditions of the jail would break even the strongest men.
I was transfixed and with great respect visited Savarkar’s cell. Veer Savarkar was kept in a cell (strategically) just opposite the gallows – so that he can see the prisoners getting hanged. The man had written – in Hindi – a poem to the birds,
“I don’t know your language, but If I did, I would teach you the Indian National anthem”
Even now, it’s hard for me to say in any language,including my own, what I felt at that moment. Perhaps a gush or respect , a wave of pride,love for the nation all mixed in intoxicating proportions, that I almost lost balance. It was then that the unthinkable happened.
Several people behind me had been making noises, smoking and making fools of themselves generally. In spite of admonition from the guide, they paid little heed to the sanctity of the ground they were treading. It was a generation that didn’t have to deal with British atrocities. The irony of the situation wasn’t lost on me – that they were able to do that in Cellular jail only because of the sacrifice of thousands of freedom fighters. Sometimes when you get something, without toiling for it, you hardly understand its value. These ungrateful brats had the temerity to go to gallows and make some stupid jokes!
Life had come a full circle. From the time when we were united and used every means to wrest freedom from a cold empire, we had become a nation with no pride or self respect. I,Me and Myself had become the dominant personal ideology. The government had embraced a politics of anything goes and by natural progression, scams rocked the country. The regularity of these scams would put any Swiss watch maker to shame.
I had little idea of Modi or BJP then. Nor was I particularly aware that nationalism was an antidote to the plague I was witnessing. I was one of those happy go lucky guys whose life revolves around a book, a laptop and a cup of coffee. I was decidedly apolitical. Of course, just because we don’t take interest in politics doesn’t mean politics won’t take interest in us.
The questions kept haunting me through out my honeymoon – just like the rhythmic waves that hit the beautiful beaches of Andamans. Why did these people feel no respect or love for the freedom fighters? Why were they not proud of their heritage? Where did we lose the plot? More importantly, what is the solution?
Of course, it was apparent that in a vast and diverse country like India, it is juvenile to expect a knight in shining armor to come and change things. It was also clear that we were at cross roads in history – a decisive moment – when things can only change for the better, if there is a thorough overhaul of the dominant narrative. The political discourse needed some shaking up. We needed to find some way to unite the country – the sleeping giant – and gear up to take a larger role in the world stage.
It was then that Modi happened. The social media powered campaign was a blitzkrieg. Like so many of my country men, I came under his spell. We see only what we want to see, and believe someone who says what we want to hear. He was a master orator and I cursed myself for not knowing enough Hindi to understand his speeches.
Three years on – when I look around – I am happy that things have finally started to change.But sometimes it’s hard to shake off the feeling that we might have gone overboard. The duality has become quite stark – not that is always bad – after all , if you looking at good and bad, you can’t complain of them being totally different. The media has become more polarised – so much so that it’s hard to tell what is true these days. The quality of public discourse is laughably poor – incessant fights on language, religion and caste continue to plague us.
As India has become a global power to reckon with, our vulnerability to external threat has diminished substantially. To put it in our PM’s words, India of 2017 is not the same as India of 1962. The standoff in Doklam and China’s cautious approach is ample testimony to this fact. Our growing clout is undeniable.
Unfortunately we are quite vulnerable to ourselves and our folly. We may have become more divided nation – or so it seems. The very drug of nationalism which was intended to treat the apathy has now reached militant heights. The shrill cry of hypernationalism is threatening to tear the fabric of our cherished diversity. After all, our flag is a tricolor, not some monochrome.
I was and still remain a subclinical sanghi. I do wonder if my political pendulum is beginning to swing towards the centre. On this glorious Independence day, we must realize that our differences don’t matter as much as our shared history and bonds. We need to tell our kids that we take great pride in our Indian identity- the primary identity of all of us.Just like our forefathers who toiled hoping that their children and grandchildren would one day live in a free India, we need to work hard to ensure that we don’t drop the baton. We owe it to those brave souls who shed their blood and sweat in cellular jail.
Happy Independence day!
Today morning, I opened The Lancet, to see an interesting Statin trial that looked at SAMS (Statin associated muscle symptoms). You can read the trial here
Adverse events associated with unblinded, but not with blinded, statin therapy in the Anglo-Scandinavian Cardiac Outcomes Trial—Lipid-Lowering Arm (ASCOT-LLA): a randomised double-blind placebo-controlled trial and its non-randomised non-blind extension phase
Statins are cholesterol lowering drugs that are sometimes associated with muscle pains. Unlike myopathy or myonecrosis, muscle pains have no objective biochemical or histological component. The authors had analyzed the statin related adverse effects during the blinded(patient doesn’t know he’s taking statin) and the unblinded(patient knows he’s taking statin) phase of ASCOT trial. When the patients knew they were taking statins, they complained of muscle pains. When they didn’t know what they were taking, they had no symptoms !
In other words, their expectation of what statin might cause (after learning about it from net/other sources) influenced their symptoms. This fascinating phenomenon is called the nocebo effect.It’s the negative cousin of the well known placebo effect. It reflects changes in human psychobiology involving the brain, body, and behaviour rather than drug toxicity.Muscle related adverse effects are often low in randomized trials compared with observational studies. The strength of this study is that these were the same patients, no run-in period existed to exclude patients intolerant to therapy, and few patients had previously taken any statins.
This reminded me of some of the unfortunate posts on marriage I ve been seeing in Facebook and Quora of late. The liberal rants have an unmistakable pattern – they claim that marriage is the worst thing that can happen to a person. There are some sites (such as this one) whose only job appears to “educate” people on the evils of marriage and praise any and every form of decadence. You can see this in present day movies as well – the premise is that if you get married you are screwed. All these sources happen to think the plural of anecdote is data – it’s not.
It’s possible this can have a “nocebo effect” on our youth – for example,some of the fine boys I know appear to have become unusually nervous at the thought of getting married. Such negativity may even become a self fulfilling doomsday prophecy. At the expense of committing the same sin as the liberals(the plural of anecdotes!), I must say there is nothing to be afraid of about marriage. Sure,occasional mishaps happen – but they are ,thankfully, still not the norm. Of course, our world view is colored by our own atomized experinces. I am also aware that just because,my experience is overwhelmingly positive doesn’t mean everyone’s will be the same. In any case, it’s important to keep an open mind. Negative thoughts are clearly useless.
PS: Here’s a pro tip: Stay away from the leftist/liberal websites that spew constant trash, if you can. You won’t regret it.
Yesterday I attended an annual internal oration on the cancer scenario in India and the challenges that lay ahead. With abject poverty, woefully inadequate infrastructure and acute shortage of oncologists in several parts of our country, the stats predicted a bleak future.It appeared as if we were going to a nuclear war armed with sticks and stones.In this hopeless scenario, I was reminded of one of my heroes, a man who fought against impossible odds and scripted one of medicine’s most glorious victories.
The year was 1957. A middle aged surgeon was working in Uganda, in the Mulago hospital in Kampala.He was a devout Christian and considered himself a missionary. By his own admission, he wasn’t a great surgeon.What he lacked in surgical genius, he made up for in tenacity. One day a boy named Africa who walked into his clinic. The malnourished boy had a large swelling in his jaw-making him look grotesque. In a few days, the boy died of his tumor. A couple of weeks later another boy walked into his clinic, with the same kind of swelling and met the same end eventually. The surgeon was intrigued – by the striking similarity of the cases and the ferocity of the tumor. He decided to investigate.
He had a handicap though – a stray bouncer had damaged one of his eyes permanently during an adoloscent cricket match. He was aging and was working in Sub Saharan Africa -far from where the limelight usually shone in medicine. He had no funds or even great expertise to draw upon. The people he treated were poor and wanted some solace for their pain, not fancy research.
Nevertheless with characteristic zeal, he asked around if doctors had seen similar cases. They said yes – so he pored over the records and to his astonishment found several similar cases, all of them ending in death. No one had connected the dots till then. He then looked at the literature – sure enough, there was an article about a similar tumor in 1901 in an obscure tropical medicine journal. The tumor he had seen wasn’t new. The pathologists had reported each of these tumors as sarcoma.
He quickly wrote a manuscript titled “A sarcoma involving the jaws in African Children” and posted it to the British Journal of Surgery. The reply never came.
By sheer accident, he met a physician called Oettle in South Africa. Oettle was younger and his star was on the ascent. By now the surgeon had collected grim photos of his patients. He showed Oettle and asked about similar cases in South Africa. Oettle waved his hand and said these cases didn’t exist in South Africa.
With no formal training in epidemiology, the surgeon decided to send out questionnaires with the photos to doctors across the country. The pace was excruciatingly slow – it took around 4 years for 400 responses. Armed with the information, he represented each case with a pin on a map. Since he couldn’t afford colored pins, he painted the pins with his daughter’s paint himself. A pattern was emerging. The tumor seemed to have a geographical distribution.
He presented his finding in Middlesex. Little did he know that his presentation would trigger a multinational effort against a common enemy.Among the audience was a man named Tony Epstein, a British pathologist. The idea of an infectious agent causing the tumor began to emerge. There were skeptics – unlike other infections, there are no cancer epidemics. Nor did the brothers and sisters of these unfortunate children get the disease. What kind of infectious agent behaved like this?
The surgeon decided to do a ‘geographical biopsy’. He applied for funds and got a 15 pound grant from the British government. With that and the help of his friend, he took an old four wheeler, repaired it and started on a long Safari. In sweltering heat, he would travel to Johannesburg and then back to Kampala, covering a total of 12 countries! In each place, he collected data (even before that term became entrenched in medical literature). On a hunch,he got external review of the old slides. The results surprised him. The tumors were neither sarcomas nor carcinomas. The originated from lymphoid tissue- a lymphoma. Under the magnification of a microscope, these small round cells resembled a starry sky.
Tony quickly enlisted the help of his friend Yvonne Barr. Since they coudn’t isolate the infectious agent – it was too small – they decided to try a different approach. They looked for antibodies to the small infectious agent – presumably a virus. Sure enough almost all the cases had antibodies directed against this agent and it even stained the tumor cells. At long last, they had discovered the first human cancer caused by virus, one that bears their name – the Epstein Barr Virus.
Meanwhile the surgeon’s name became popular in medical circles and he received an offer to try methotrexate in these children from Sloan Kettering. To his amazement the tumor melted in these children. It returned in some. So he begged for another cyclophosphamide from an American manufacturer, which managed to hold the emperor of all maladies at bay even if for a short while.
This is the story of how within a decade a cancer was discovered, its morphological fingerprint identified, its geography dilineated, its causative agent discovered and its treatment started.It is the story of how an one eyed Irish surgeon, saw what all others had missed. It is a story of discovery that spans several continents in the face of impossible odds. It is a story that shows than even the ordinary can achieve great things with perseverance.
So when you feel overwhelmed that you are in some remote no man’s land fighting a lone battle, remember this surgeon.
The name is Burkitt. Denis Parsons Burkitt.
You might be curious about trying out a linux distribution , but perhaps you don’t have the time or energy to go down blind alleys or dead ends. With the fragmentation of the linux ecosystem, you are not sure which distro you should pick. In this post, I explain I chose OpenSUSE over all other distros (and perhaps convince you to install it as well.)
Most new linux users would start with Ubuntu linux( or one of its flavors) or Linux mint. My first exposure to linux was through Ubuntu too – and I hated Unity. It’s not an overstatement, just a fact. It was ugly,clunky and not very fast either on my rickety old system with a Core 2 Duo processor and a 2 GB of RAM. I didn’t want to let go of the eyecandy either – so I tried the most beautiful linux distro ever- Elementary os.( it’s not a coincidence that is a Mac clone). It was unfortunately not as mature as I would have hoped. I moved from Luna to Freya to Loki finally and all that happened was just a little polish here and there.
There comes a point when you get tired of all the tweaks and tricks. You long for a stable system that just works. Don’t get me wrong, I am quite comfortable with the command line. What I don’t like is a system where I spend too much time fiddling, and too little time actually creating anything.
So I graduated to the second tier of linux distros – Fedora. Fedora has a great user community. It feels polished, fast and mostly stable. I didn’t go for the rolling release version of Fedora. Somehow the old troubles came back to haunt me – again I was fiddling with the command line, hanging out in the IRC and going through the man pages for simple stuff. It was all a little tiring.
So I decided (albeit quite late) that the choice of the distro should only be dictated by my needs. So here’s a list of my needs
Now that I was clear about my needs, I eventually gravitated towards OpenSUSE Leap 42.2. It’s been a month now and I have never looked back. When they said YaST was the best package manager, I thought it was just hyperbole. Never did I think I would be echoing the sentiment 30 days later.
It feels polished, incredibly stable and easy to use. More importantly it comes preloaded with most of the apps a common user will want and adding more is so easy. Zypper is the command line utility for package management, but with YaST I have rarely had to use it. There are hiccups/cryptic error messages. The file manager, Dolphin, is the best in class.
Like a great companion, it has grown on me.So much so that I felt compelled to write a blog post about it. It’s less about facts and more about emotion, of someone who has been distro hopping for a long time and has finally found his home.
OpenSUSE 42.2 Leap dual booting with Win 7 on a Core 2 Duo Desktop that is 10 years old.
Here are some apps OpenSUSE ships with
Getting additional software is easy and there is no need to jump through hoops like other distros.
Future linux distros to try: Manjaro Linux (based on Arch)
This blog is purely academic in nature and I have resisted the urge to post stuff with political or social connotations here. However, desperate times call for desperate measures.So while this post is not actually academic it is an attempt to infuse some framework into a social( and hugely emotional) debate.
In the last few days our state has gone through an unprecedented student revolution, triggered by Tamil identity and engineered largely through social media. In the din of sloganeering, the social significance of this movement can be easily missed. We have witnessed the first ever(and the largest) non violent mass uprising in the history of post Independence India. The orchestration of protest on such a massive scale by a rag tag group of students and activists without much political backing is a feat in itself. The judiciary and the executive have been shown that they are not above the people.
At the same time, one wonders if this augurs well for the future? The reluctance of the Honorable Supreme Court and the Government to acknowledge the sentiments of Tamil people has resulted in an awkward situation. This has caused a huge dent in the faith our people have in these democratic institutions.
A flurry of allegations and counter allegations have effectively shrunk the discussion space. The fake news and inflammatory articles have served their intended purpose.The identity politics and the politicians who peddle them have had a field day. Science has taken a backseat.
Some have suggested that a ‘nuanced debate’ is what we need. Debates are incredibly useful tools for learning. Yet the need to win a debate, can paradoxically make the debaters blind to the views of the opposite side. The audience on the other hand can be easily swayed by the debating or linguistic skills of one or the other debaters. So while debates are useful tools, they are just that – one among the many tools available to us to learn. They are just part of the puzzle, not the whole.
Just like we immunize our children against several diseases, we need to teach them thinking skills – to immunize them against a variety of future onslaughts : from demagogues to delusional retards. We need effective thinking frameworks.
It doesn’t matter whether you support or oppose Jallikattu. The issue is how you reached the conclusion. The process is as important as the outcome.
Here’s a glimpse into a thinking framework in the context of jallikattu.
Whenever you are given a choice between X and Y, you must guard against possible narrow framing. Ask what about Z?. In this case, the question is not whether Jallikattu should be banned or not. It is not whether bull taming is cruel or not. The real question is
What is the best way to promote sustainable and humane cattle rearing without endangering the livelihood of our farmers and decimating the local breeds?
When you ask the right questions, you may not have readily available answers. But then it is a lot better than asking wrong questions and wasting time by going down the wrong alley. What can you do when the third or n’th option is not immediately apparent?
Some things you can do include
For PETA supporters : If Jallikattu ordnance is passed, what is the best way to ensure that animal cruelty is avoided?
For PETA supporters : Can this be a precursor to a natural experiment? If Jallikattu is allowed in Tamilnadu, you can collect prospective data on rearing practices, milk quality, disease epidemiology etc and compare it with other states or even other countries.Of course, this won’t be as good as a randomized study, but it will be better than nothing.
Every decision we make involves some assumptions. The trick is the acknowledge and reality test these assumptions. This will help us guard against confirmation bias.
Things to do :
For PETA supporter : If you think animal cruelty is involved , think how you can verify this from reliable primary sources. The best way to end a debate on whether it is raining is to step out. Volunteer to watch a Jallikattu event and decide for yourself. If not , put yourself in the shoes of the farmer – this shift in perspective can give useful insights.
For PETA supporter: Try and understand the larger cultural and historic undercurrent to the issue. Collect data on reports of animal cruelty. Be aware of publication bias – only the interesting findings are reported often. If a dog bites a man, it’s not news. If a man bites a dog, then you have news! Don’t be blinded by the idea that those who are unsophisticated don’t know what they are doing. Remember they have been doing this for centuries. Try and learn what works and what doesn’t.
This is perhaps the most commonly violated principle. Seriously. There is no need for us to jump to conclusions. By deciding too early and vociferously supporting something we don’t understand well, we might put ourselves in a corner from which backtracking would be difficult. My personal idea is to wait a while – for the heat of emotions to wear off and some clear thinking to kick in.
Things to do
For PETA supporter: If you know what you do today, thanks to a counter push from the Jallikattu supporters, would you still support ban on Jallikattu?
This is the last and the most important principle of the framework. We are often over confident about our own decisions and this can have disastrous consequences. Future is not a point, but a spectrum of possibilities. We must always realize it’s ok to be wrong – it is the risk one has to take in the quest for truth. The journey won’t be easy – it’s not meant to be. However it is rewarding. So the best we can do is risk mitigation – to have a plan B.
Some things to do to uphold this principle:
For PETA supporter: It is one year from now and you have lost the struggle. You feel the government has caved under the weight of populist pressure. What can you learn from this ? What are the positives and negatives?
For PETA supporter: If you feel you have underestimated the popular support for this sport, where did you go wrong? Which pattern did you miss? Is this the proverbial black swan, with no way of knowing in advance, or this is something you could have predicted? In the event of a future Jallikattu, which is the earliest warning sign of animal cruelty that you can choose as a trigger?
As you might realize by now, the framework is data agnostic. It doesn’t require you to have a ton of data to start with. However each component is dynamic and accommodates accrual of further data. Crucially it can be used for any problem.
Regardless of which side of the debate you are on, it is hard to deny that you learn something from opposing views. In this regard, I believe in Quora’s BNBR policy – Be nice, Be respectful. I see opposition as a strategic resource- of opposing ideas. Nothing more, but most importantly nothing less.
I believe that more than debates, critical thinking and logic must be taught in schools and colleges. Otherwise we will continue a citizenry that doesn’t think and a body politic that manipulates the gullible.
The key thing is to deliver procedural justice. To restore the faith in the process. To fortify the system. To enable a reasoned discourse.
Yes, I support Jallikattu. I have done my due diligence. I have consciously fought my cognitive biases as best as I could. Nevertheless I am prepared to be wrong. I am confident that Jallikattu ban will be lifted. If not, I am equally confident our students won’t do anything rash.
For we live today to fight another day.
(This article is a tribute to all students and activists who have fought tirelessly against impossible odds. You have proven once again that not all superheroes wear capes)
I was thumbing through the pages of a diabetes book,when I came across something that sent me down the memory lane. Some cases are so strange they remain etched in your memory forever.
It was the first year DM . I was taking stock of the newly admitted patients, when I saw a patient a little sicker than usual in an endocrinology ward. I glanced at the case sheet -it mentioned the patients name , ArokiaMary Janthubak, along with the serpentine path she had taken to reach the endocrine ward. She was poor and as always poverty made her look older than her 34 years. I couldn’t see any kids around, but then she was in no shape to think about them at that time. Her husband seemed pensive and oddly distant. In any case,he had every reason to be unhappy.
She had been admitted with diabetic ketoacidosis. The culprit was a usual suspect – missing medication , with an unusual accomplice – myonecrosis of the thigh. This rare condition causes the muscle to die,only to be replaced by pus. Palpating gives you a doughy feeling. When this happens, one can be sure that diabetes has been badly managed for a while.
I called the surgery resident who came and did the usual I and D. The wound was huge, and the gutter left behind looked like some kind of subway on her thigh. I was getting a bad feeling about the whole thing, but I couldn’t put a finger on the source of my consternation. The surgeons having done their part, left us to do ours and we gave insulin infusion. The labs suggested that the kidney had taken the hit,but nothing too serious.
One more day passed and she wasn’t getting any better despite our best efforts. Like most problems which seem to have a mind of their own, disaster struck the next day night. The patient had anemia and perhaps the blood loss and the whole infectious ordeal had become too much for her failing heart to handle – she developed pulmonary edema.
We needed a central line for fluid management. As luck would have it, our ward had no central venous catheters. And a frantic sos call to the ICU had yielded nothing. So I prescribed an single lumen catheter. It would cost about 700 rupees. The patient s husband didn’t have the money,so I did a mini fundraiser and sent him off immediately.
That was the last time I would see him.
By some much needed stroke of luck , we managed to get a central line in her IJV. The next day, the other men in the ward caring for their wives and children told me the man is a drunkard and he must have had a good booze with the money we had given him. Even by the fairly diluted moral standards I was used to, that was callous. We were now in a bad situation: a sick patient with no money and no next of kin.
I asked her, if she had a brother or sister we can call for help. She said she had a love marriage and her family had all but abandoned her. This isn’t really uncommon and I felt bad for her. The same night, she developed seizures and a stroke in hospital and our luck ran out. She died alone on that night.
A phonogram was sent to the address in her case sheet. The local police bring back the fellows who abandon their relatives in government hospitals if you send a phonogram. And since the police have a lot on their hands, you can only imagine the methods they would use.
I was hoping against hope for the husband’s return. But the police could find no trace of the husband -Janthubak. The phone number turned out to be fake as well. The people around me asked “yaaru sir Janthubak nu paer veppa?appove neenga yosichiruka venam? ( who names their son Janthubak ? You should have been more alert)
I still couldn’t believe a man would go to such extremes to dump his wife. And that too after a so called love marriage. I felt sick. I was no Sherlock Holmes but Janthubak will always remain my Irene Adler- the one who got away.
A couple of weeks passed and we had moved on. A couple of men and a woman came to meet me, claiming they were the siblings of the deceased. I told them it was too little too late. As I was about to admonish them for their utter lack of decency, they took out a phone and showed me the photo of a couple of children. Both looked haggard and a tad malnourished.
I asked them what they were doing . They told me it was the patients children. She had abandoned them and her husband to elope with the now mysterious Janthubak. They told me his real name was John or something (ironically I don’t remember his real name well). The children had been effectively orphaned.
It was a sucker punch and I took a couple of seconds to recover. We are taught to see patients as humans with feelings, empathise with them and never judge them. At times it can become very difficult. Despite my best intentions, I could see a faint trace of poetic justice. And a growing feeling that no one really gets away- fate eventually gets us all.
Some noise brought me back to the textbook. As I looked at the name of the drug , I wondered if anyone would name their brainchild as empagliflozin