… Vīta-rāga-bhaya-krodhah (Gīta 2.56)

The other day I had the honour of making a presentation to the faculty and students of NICMAR University, Pune on the topic: Values and Ethics: Revisiting Indian Knowledge System. 

As I hurriedly concluded my presentation drawing the attention of the audience to a verse from Yajurveda, “… may we look on one another with the eye of a friend” (xxvi-18), a young lady from the front row of the auditorium posed a question: “some people, for no valid reason, shout at you and you can’t give them back but it causes a lot of stress. How to handle that stress? Am I to simply accept it? But it causes a lot of stress … a lot of stress.”

I could see the pain of it writ large in her face. I did respond to her question, though hurriedly. Nevertheless, we shall now examine it in detail.

First things first: Let us first understand what stress is. Stress is the body’s response to a stressor. A stressor is a trigger that may cause one to experience physical, emotional, or mental distress and pressure. In the instant case, the stressor is: the uncivilized behaviour of the person who yelled at the lady for no valid reason. This rude behaviour triggered a feeling of being overwhelmed and she could not cope with the pressures caused by it.

A stressful situation triggers a cascade of stress hormones which produce well-orchestrated physiological changes in our body. A stressful incident makes the heart pound and breathing quicken. Muscles tense up. Beads of sweat appear.

This kind of reaction to a stressful event is also known as the “fight-or-flight” response. For, it evolved as a survival mechanism. It enables people to react quickly to life-threatening situations—activates one to fight the threat off or flee to safety.

Unfortunately, there is a flip side to it: the body can also overreact to stressors that are not life-threatening such as the yelling of somebody at you, traffic jams, deadlines at work, etc.

Over the years, researchers have learned how and why these reactions occur. When a person encounters a threat, say noticed a cobra on the path, the eyes send the information to the amygdala—the part of the brain that handles emotional processing. Interpreting the images and perceiving them as dangerous, amygdala instantly sends a distress signal to the hypothalamus.

In turn, hypothalamus communicates the threat to the rest of the body through the autonomic nervous system, which consists of two components: One, sympathetic nervous system that functions as a gas pedal in a car, and two, parasympathetic nervous system that functions as a break.

On receipt of a message from hypothalamus, sympathetic nervous system by providing a burst of energy to the body, triggers a fight or flight response to the perceived threat. Once the threat is passed, parasympathetic nervous system calms the body by promoting a “rest and digest” response.

On receipt of a distress signal through sympathetic nervous system, adrenal glands also get activated. They respond by pumping the hormone epinephrine into the bloodstream. The circulation of epinephrine in the body brings a number of physiological changes: heart beats faster, pulse rate and blood pressure go up. Breathing becomes more rapid. Epinephrine also triggers the release of sugar into the bloodstream. All these changes happen so fast that without being aware of them, we even jump out of the path of the cobra well before we realize what we are doing.

Once the surge of epinephrine subsides, the hypothalamous activates the second channel of the response system: HPA axis. It consists of hypothalamus, pituitary gland and adrenal gland. This axis aids the brain to keep the ‘gas pedal’ pressed down. In the event of brain continuing to perceive the threat, hypothalamus releases corticotropin-release hormone. Travelling to pituitary gland, it will trigger the release of adrenocorticotropic hormone. This, in turn, travels to adrenal glands and nudges them to release cortisol. Thus, the body remains on high alert.

Once the threat passes, cortisol levels fall and the parasympathetic nervous system applies brake and dampens the stress response. But many people fail to apply brakes on stress. This leads to chronic low level of stress, which is likely to cause health problems at a later date. Persistent release of epinephrine damages blood vessels. It also increases blood pressure. In turn, the risk of heart attacks or strokes stand enhanced. Increased levels of cortisol may also lead to overweight.

Fortunately, we can learn the techniques of managing stress responses. Psychologists say that stress is produced not by events themselves but by one’s reaction to events (stressors). It is precisely because of this that we see people reacting to a given stressor differently. 

For instance, let us take the lady’s problem of somebody yelling at her for her no fault as an example and see how two people react to the same problem differently. The man who gives least importance to such yelling believing that it was the habit of the yeller (yo tho pagal hai, aise chillata hai) and deserves no attention, simply walks away from it. On the other hand, the man who takes it as personal insult cannot but brood over it: “Of all the people why to me? I behave so soberly, never tread on others’ toes, I speak so gently, and yet why this man yell at me? That too, in front of so many?” If you keep on agonising like that over what had happened for days together, your hypothalamus will keep HPA axis active —‘the gas pedal’ remains pressed down. Which means, release of hormones into bloodstream continuously, which in turn, keeps the body on high alert. This results in chronic stress that can later lead to cardiovascular problems.

Instead, realising the fact that it is our thoughts that influence our emotions, and it is these emotions that influence hormonal secretions and our behaviour, if we could reframe our thoughts about the stressor—rude behaviour/yelling, etc.—we can certainly help ourselves in reducing feelings of stress. Suppose in the instant case, if we could think of the yeller as a man with no culture and hence his yelling merits no cognizance, we may be able to walk out of the incident coolly. Which means, we can manage the stress emanating from the scene appreciably. 

Research indicates that such cognitive behavioural therapy (CBT) works better in managing stress. This technique is not limited to the present case alone: whenever you feel yourself spiralling into worst-case scenarios, you better switch your mind elsewhere. Or, stay connected with people who can provide you emotional support by listening to you empathetically. Such diversions are likely to relieve you from the overwhelming stress.

Here, it is in order to quote what lord Krishna said in Gita: “yaḥ sarvatrā nabhisnehaḥs, tat-tat prāpya śubhāśubham, / nā bhinandati na dveṣṭi, tasya prajñā pratiṣṭhitā (2.57)—He who is without affection on any side, who does not rejoice or loathe as he obtains good or evil, his intelligence is firmly set”. Such a man is termed by him as a Sthitaprajña. A Sthitaprajña is not disturbed by the touches of outward things. He does not rejoice over good (adoration from a colleague/boss), nor lament at the bad (yelling of a stranger/boss). So, his/her prajñā— intelligence remains stable. A stable mind can rationally analyse a given situation and wisely steer out of it with the least stress.

We may have to therefore cultivate the state of being Vīta-rāga-bhaya-krodhah—free from attachment, fear and anger (Gita 2.56)—as CBT for managing stress. Are you wondering: Easier said than done? But then, is there any alternative remedy?

**

 

 

Sleep: “A Non-negotiable Biological Necessity”

The other day, while going through the camera-ready copy of the magazine before releasing it to the press, I noticed an interesting snippet under the head, ‘Features’. It tells us that an Indian corporate, called Wakefit.co engaged in the business of D2C home and sleep solutions has rolled out a unique policy of granting its employees a ‘right to nap’ for half an hour period between 2.00 pm to 2.30 pm at the workplace.

Quoting a study of NASA which states “that a 26-minute catnap can enhance performance by 33%, Ramalingegowda, Director and Co-founder of the company said that his company “has declared 2 pm to 2.30 pm as official nap time”. Hoping that such a rest shall help its employees recharge their bodies and refocus on the task at hand with a renewed vigour, the company is encouraging its employees to avail the well-deserved break.

This initiative that is primarily meant for preventing ‘employee burnout’ is hailed as a step in the right direction, for it can “foster a culture that strongly encourages self-care” among the employees.  

This incidentally reminds me of what Mathew Paul Walker— professor of neuroscience and psychology at the University of California, Berkeley, who studied the impact of sleep on human health— wrote in his bestselling book, Why We Sleep: “Sleep is a non-negotiable biological necessity”.

It is a fact that in today’s life there is no more intractable health problem than sleeplessness. Night shifts in call centers, out-sourcing offices, back offices, software companies, etc have drastically changed our sleeping habits. Commuting for long hours, travel, stress, and excessive caffeine intake have further aggravated sleeplessness. Even old age, by itself, makes one spend the night tossing and turning to leave one tired, cranky, and out of sorts by the next morning. In medical terms, the cumulative effect of them all is called insomnia.

Of course, insomnia won’t kill us. But it mars our normal life. Sleeplessness seeps into every bone and muscle making the body feel as though lifeless. It erodes our very well-being. Feel tired/fatigued during the day. It distorts our attention. Concentration lapses. Coupled with poor memory, work becomes a drag. Output, turned out, will be of poor quality. Irritability overrides pushing us into a depressed mood.

Poor quality sleep indeed affects every organ of the body. It affects our cardiovascular system, metabolism, immune system, nervous system, and brain as well. It increases our vulnerability to disorders such as high blood pressure, cardiovascular diseases, diabetes, depression, and obesity—diseases that are all known to shorten our lives.

Lack of sleep is also known to reduce the antioxidant defense mechanism of the body. It inhibits the ability of the body to annihilate molecules such as free radicles and oxygen-reactive substances that are known to damage cells and cause inflammation. 

However, it is still not very clear how sleeplessness causes these effects. But present knowledge indicates that we need good sleep because:

• It helps our brain to forge new synapses and solidify memories, experiences and emotions
• It facilitates the brain to filter out unimportant synapses and thus reduce its overload.
• It detoxifies the brain by removing unwanted cellular detritus and potentially damaging protein molecules such as beta-amyloid which is associated with dementia through a mechanism recently identified as the “glymphatic system”. This drainage mechanism is supposed to work twice or three times faster during sleep vis-à-vis while we are awake.
• It also helps the brain to repair itself by removing “free radicals” that are known to cause “oxidative stress” in the brain cells.

Now the big question is: How much sleep one should have to realize these benefits and more importantly how to ensure it? Cleveland Clinic suggests that adults need around seven to nine hours of sleep per night, though the quantum of sleep that one needs to function at one’s best varies from individual to individual. They also stress the importance of the quality of sleep. Their doctors say that lifestyle changes, as indicated below, can often help one sleep better:

• Avoid large meals, caffeine, and alcohol before bed
• Be physically active during the day
• Cut back on caffeine, sodas, and chocolate
• Go to bed and get up at the same time each day, including weekends.
• Put away smartphones, TVs, laptops, and such other screens at least 30 minutes before bedtime.
• Turn your bedroom into a dark, quiet, cool sanctuary.
• Retire to bed listening to soothing music, reading a good book, or meditation.

Such behavior modifications have proved to be effective in avoiding sleepless nights for many but if it didn’t help, one must obviously seek medical help. For, “sleep is a non-negotiable biological necessity”.

Monkeying Around Monkeypox!

Monkeypox is a disease caused by the infection of monkeypox virus. It belongs to the genus Orthopoxvirus and family Poxviridae. The genus Orthopoxvirus also includes variola virus, which causes smallpox and vaccinia virus that was used in the manufacture of smallpox vaccine, and cowpox virus.

It was first reported in monkeys maintained in a laboratory for research in 1958. The first human infection of it was reported in 1970 when a nine-month old child from Democratic Republic of Congo, was infected. Nigeria too reported a monkeypox infection in humans in 1970 and two more in 1978.  

For almost four decades thereafter, there was no reporting of monkeypox. But in 2017 it re-emerged in Nigeria. Between September 2017 and April 30, 2022, it has reported 558 cases. Among them, 231 have been confirmed by laboratory. Since then, dozens of cases were reported from Nigeria year after year.

Based on the clinical examination of confirmed cases from Nigeria during 2017-2018, researchers have found that the virus transmits primarily from an infected animal or from an infected person. Transmission from animal to man occurs through broken skin or through direct contact with an infected animal’s blood, bodily fluids, or pox lesions. Man to man transmission occurs when one comes in contact with the sores, sobs, respiratory droplets or oral fluids of an infected person. One may even pick it up by coming into contact with recently contaminated clothing, bedding and other clothes used by an infected person.

Bill Hanage, Associate Professor of epidemiology from Harvard TH Chan School of Public Health, commented that many early cases were noticed among gay or bisexual men, and people with multiple sexual partners. There is however no evidence to indicate that the virus transmits through semen or vaginal fluids. It is believed that it is the skin-to-skin contact during sex that might have resulted in the virus spread.

Epidemiologists say that it may take several days to a few weeks for an infected person to develop symptoms. Early signs of infection may look-like flu-like symptoms: fever, chills, headache, muscle aches, fatigue, and swollen lymph nodes. After a few days, a rash often develops. Rash may start as flat, red-bumps and they may be painful. Later, these bumps may turn into blisters which fill with pus. Over a period of two to four weeks, the blisters may crust over and fall off. One may also get sores in mouth, vagina or anus.

In the current outbreak of the disease, it is noticed that all the infected persons need not necessarily develop all these symptoms. Some may have relatively few blisters than what is normally expected. With the result, there is a likelihood of misdiagnosing it as other infectious disease. Here the danger is the infected man though not showing any symptoms could still transmit the virus to others. Of course, the rate of spread of the disease by an infected person is still not known. It is only with the spread of the disease from Africa to Europe and North America, that researchers have noticed large-scale human-to-human transmission. 

But what is most intriguing about this disease is: while monkeypox outbreak was noticed in Nigeria as early as in 2017 and subsequently dozens of cases were reported from time to time, no international attempt was made to stop the outbreak in Nigeria, nor did any agency paid requisite attention to research the disease till the latest outbreak in Europe and North America,. Even to date, the host animal of the virus that acts as its reservoir is not known. In the light of this, African scientists’ accusation that till wealthy countries are effected by the disease, no one had paid attention to study the disease and its spread sounds true.

For, it’s only after the disease was spread to Europe and America that the researchers from Portugal uploaded the first draft genome of the monkeypox virus detected in the country. But as Gustavo Palacios, virologist from the Icahn School of Medicine at Mount Sinai, commented, more work needs to be done to draw definitive conclusions about the disease. All that the researchers are saying today based on the preliminary genetic data is that the virus found in Portugal is related to a viral clad that was predominantly found in West Africa, which was found to cause milder disease with a lower death rate of 1% in rural population.

Of course, it is still not known for certain if this is the same strain that is causing concern across England and North America. True, currently genome sequencing is being carried out actively, and till date 15 genomes are reported to have been sequenced. And theoretically. this being a DNA virus, mutation rate would not be that alarming as in the case of RNA-virus. However, nothing is still known about its mutation rate for certain. So, what is needed is more research to know about its source animal and causes under the current occurrence of the disease in the hitherto non-endemic countries.

Despite the fact that the current spread of the monkeypox disease is commented by virologists as an “eye-opening” kind, scientists believe that it would fizzle-out on its own: it will not spread that easily between people and there is a vaccine to prevent it and it is easily noticed when somebody’s got it. They say it would not certainly become a pandemic. Let us join them in that hope but keeping ourselves well informed about the latest findings about the disease.

That said, we must also remember that once a new disease is noticed—be it in Africa or elsewhere—threatening mankind, it is incumbent upon the rich nations to show solidarity by undertaking requisite research for its control….. For, it is a matter of a few months for a new disease to spread to the rest of the world from its place of origin.....

 

Covid-19 & Religious Tourism Won’t Go Together

Pilgrimages to holy sites have no doubt immensely contributed to the development of geographic, cultural and civilizational horizons of nations in all religions of the world (Singh, 2004). They are the oldest form of tourism. India and her religions are no exception to this phenomenon. The good part of them is that they are changeable: interactions of religious, social and natural factors occurring within the geographic space of pilgrimages do result in such changes (Cohen, 1992; Coleman & Eade 2004; Digance 2003). Covid-19 is one such natural factor that has radically changed the traditional regular pilgrimage movement world-wide.

Against this backdrop, it is in good order to congratulate Mr Pushkar Dhami, the new Chief Minister of Uttarakhand, for his bold and rational decision of banning this year’s kaanwar yaatra due to the ongoing Covid-19 pandemic. Thanks to his foresightedness that other states like UP, Bihar, Jharkhand, Odisha, and Delhi immediately followed him by banning Kanwar yatra. His was a wise decision of significant bearing for reasons galore.

First things first: millions of religious-minded people undertake Kaanwar yaatra to fetch sacred water from the Ganga at pilgrimage centres such as Haridwar, Gaumukh, and Gangotri in Uttarakhand and Sultanganj in Bihar. These Yatris (pilgrims) could obviously become the potential super-spreaders of the coronavirus across the country.

At least that’s what the past incidents warn us: at the beginning of the first wave in early March 2020, of about 4400 covid-19 positive cases in India, nearly a third were said to be related to the religious gathering at the Markaz, the Jammat headquarters in Delhi. Government reports indicate that more than 8000 people from across the country—including people from foreign countries that were known to be hotspot nations for Covid-19—visited the Markaz.

None of them were screened for the disease till the lockdown was announced on March 25. It was a chance encounter of Tamilanadu officials with the Thailand national at Coimbatore airport that triggered a search for people who visited Markaz and their contacts to screen for coronavirus. Being alerted by this incident, the panic-gripped States launched a massive search to identify all those who had visited Markaz and their contacts to quarantine them across as many as 15 Indian states so that at least further spreading could be arrested.

The whole episode raised serious questions about lack of alertness and transparency on the part of Central Government. It is worth recalling here what a silent observer of the whole episode said: “The governments have to demonstrate greater rationality than religious people”, for it commends that government cannot afford to satisfy religious demands at the cost of rationality and the overall safety of people.

Then came the second wave like a wild fire, overwhelming the health care system in the country. It was the Kumbhamela gatherings and the massive election rallies in five states besides, of course, peoples’ indifference towards covid-19 appropriate behaviour that were identified as the underlying causes for the deadly second wave. Bad policy decisions, poor surveillance and ignoring early warnings are also cited by experts as other reasons. There were frantic calls for hospital beds, medicines, oxygen, essential drugs and tests. The mayhem caused by the second wave is well summarised in the words of a surgeon of an effected district in Maharashtra “… What is worrying is that entire families are getting infected. This is a completely new trend”.

There appears to be yet another reason for emergence of deadly second wave: the report authored by Abhishek Anand, Justin Sandefur and Aravind Subramanian (former Economic Adviser to Government of India) states that the first wave “was also more lethal than is widely believed” and it is India’s inability to perceive the “scale of tragedy in real time” during the first wave that might have caused “the collective complacency that led to the horrors of the second wave”. Based on extrapolation of state-level civic registration from seven states, the report also opines that the Covid- related deaths in India might exceed the official figure by 3.4 mn. Although estimating Covid-deaths with statistical confidence may sound elusive, they need to be factored into future programmes that are meant for handling the pandemic.

Experts now opine that at the national level, the second wave is waning. But the heterogeneity at the local level, makes one wonder if India-wide trend of a sharp decline in active cases is now sustainable or not. Because of these variations, some experts are wondering if states like Kerala, Maharashtra and Delhi with R number hovering around 1 serve as a bellwether for the third wave.

That aside, the recent sero-survey report of ICMR reveals that one out of three Indians are vulnerable for Covid-19 attack, which means the overall vulnerability for the nation still remains very high. The important takeaway from these surveys are: Covid-appropriate behaviour is still the key defence against the pandemic, non-essential travel should be avoided, third-wave cannot be ruled-out, there being no difference between sero-prevalence in urban and rural areas, villages and cities are equally at risk, and there is no evidence to rule out reinfections and breakthrough infections.

Over it, as long as the virus circulates, it has the opportunity to further evolve—spinning off more transmissible variants. The IMA President, Dr Jayesh Lele, wrote a letter to government stating that “It is painful to note that in this crucial time [when] everyone needs to work for the mitigation of the third wave, in many parts of the country both government and public are complacent and engaged in mass gatherings without following Covid protocols”. It is this kind of human behaviour that aids virus circulation and even emergence of deadly variants.

All this cumulatively vindicates the significance of the banning Kanwar Yatra by the Chief Minister of Uttarakhand. This being the reality, we the citizens must understand: The Pandemic is not over. Let us not become part of the spread of coronavirus by wearing a mask indoors in public places, especially crowded places, and physical distancing. This commitment to public health adherence is all the more important in India, for 40% of our population is below the age of 17 which is not eligible for vaccination.

Simultaneously, government agencies are required to revitalise their genomic surveillance program so that we may have a better understanding about the properties of the variants, their clinical manifestations, diagnostic tests needed and treatment—simply put to better our containment measures. To conclude, let me quote what Dr C Lahariya advised: “…[if] people don’t follow Covid safety protocols, we only help virus spread faster”, which “will largely determine the fate of next wave”.  

 

Dr TL Perumallu —An Eventful Journey from Angaluru to America

We all know that our life is limited, and have to end up ultimately underneath a white sheet, never to get up again. And yet, it is always a pain when it happens to someone we love. It’s not even easy to get used to the fact of someone being gone, for just as we think it’s reconciled, accepted, when someone or some incident associated with the gone points out to him/her, you just get hit all over again. And, ever since Rajani called us one morning from the US and with a brief prelude muttered, “Pedababu is no more”, that’s what’s going on with us. 

It’s not a year or two; it’s an association that dates back to the early 70s. To be precise, it was on June 20, 1973 that I met Dr Perumallu for the first time at his marriage. I still remember that late sultry night in Mangalagiri, when he, entering the choultry in the attire of a bridegroom accompanied by a doting battery of people, looked for a place to recline, I, being from the bride’s side, hurriedly went out and fetched a cot for him to lie down. Next day, after the marriage, he spoke to me with such warmth as if we knew each other since ages.

Such long conversations continued thereafter uninterruptedly... either on phone or in person. In one such chats, he narrated about his days in Andhra Medical College (AMC), Visakhapatnam as a PG student of general medicine. A known voracious reader of every book that had landed in the library, he almost became a sort of ready-reckoner for fellow doctors. No wonder, if he with his up-to-date medical knowledge, unwittingly, had become an affront to the faculty!

Being known for his thorough clinical as well as theoretical knowledge of medicine, when once a top-notch politician, a minister in the then Central cabinet, one Mr Bezawada Gopal Reddy, who was on a special visit to the city, was admitted to the Rajendraprasad ward of KGH for a sudden medical support, Dr Perumallu was asked by Prof Raghunathan, to be the physician in attendance to the minister. This PG student, in his usual style, opening a dialogue with the minister to elicit information about his habits to diagnose the problem, and examining him thoroughly, said: “See, cardiomyopathy is a condition that can be corrected if you give off alcohol. Well. We may, at best, give you a temporary relief with medication, but ultimately, unless you quit alcohol, no permanent cure can be assured”, hearing which the attending staff turned queer, while the minister, bursting into a laugh, uttered, “Oh, my young doctor!”

But ironically, this dependable doctor cum PG student in general medicine under Prof Raghunathan, was not found good enough for awarding MD even after appearing twice. In the cross fire of petty caste politics, petty conflicts between the internal and external examiners, etc., he had to quit the program in 1968 in sheer frustration.

But he was not the man to walk out silently: he went to Prof Raghunathan’s house and on knowing he was not at home, asked his wife to convey Dr Perumallu’s “good bye” to him and also to inform him, “Dr Perumallu’s failure to get MD is not a shame to Perumallu alone, it is equally a shame to Prof Raghunathan, for after all, he was his student.”

Of course, this brave young doctor was not the one to lose nerves; instead, in August 1968 he boarded a plane bound to Heathrow with a kettleful kajjikayalu (traditional sweet) given by his elder sister in Delhi and eight pounds in pocket to redeem his fortune… After landing in London, of course, he was to pass through harrowing experiences till he secured a job. Staying in YMCA hostel, rolled on the days by eating kajjikayalu and drinking water; and then as his eight pounds evaporated, at the advice of a fellow-boarder approached DWP to seek Jobseeker’s allowance and once secured aid, started actively visiting a few hospitals for giving interviews. Finally, he joined Brighton General Hospital, Brighton as a general physician in the geriatric ward. Within no time, he could relate himself with the old folks in the ward so much by attentively listening to their narrations/woes and explain about the functioning/dis-functioning of their organs due to wear and tear/old age, that everybody used to wait for this young Indian doctor’s visit to the ward longingly. Immediately after getting salary, he said that he bought a blazer to keep himself warm in that biting cold and shifted to a private accommodation.

Talking about his experiences in Brighton Hospital, he narrated an interesting anecdote: listening to patients systematically describing their problem, he seemed to have felt as though reading the textbook of medicine once again. These interactions with patients finally led him to realize that the symptoms of various diseases that he read in textbooks back home was not that of the authors of the textbooks but a mere compilation of what the patients had narrated to them.

In June 1970, he shifted to the US, where he did his internship in internal medicine at Toledo General Hospital, Toledo, Ohio. In July 1971, he moved to Independence, Iowa and did his first year residency (July 1971-June 72) in Psychiatry at a State Hospital in Independence. While relentlessly pursuing his desire to acquire as much knowledge as he could of various facets of medicine, he stayed focused on making a few extra bucks by attending to all kinds of hospital work, all in the anxiety of quickly pooling sufficient money for marrying off his youngest sister back home. This is one trait of him—the trait of devotedly supporting his widowed mother in managing the family, discharging his familial obligations such as marrying off his sisters, etc., that I respect most, indeed this won my reverence for him. Perhaps, feeling enough dough had been pooled up, he returned to India in July 1972 to get his youngest sister married.

In 1973, he married Dr Anjana Devi, FRCS, on 20^th June. Then marrying off his youngest sister to a doctor, he went back to US in July 1974 along with his wife to work for four to five years, make enough money and return to establish a hospital of his own in Guntur. After finishing his 2^nd and 3^rd year Residency in Psychiatry at the State Hospital, Independence, Iowa, he moved to Danville, Illinois in June 1976 to work at VA Hospital as Chief of the Psychiatry Dept. Later in June 1978, he moved to Cherry Hospital in Goldsboro, North Carolina as Staff Psychiatrist. He, working in that hospital in various capacities: Liaison Psychiatrist, Director of Behaviour Modification Unit, etc., took early retirement in December 1998 due to health problems.   

Family loyalty was a deeply held ideal for him. True to our tradition, he looked at the family from a ‘collectivistic’ perspective and was always concerned about belongingness, dependency, empathy and reciprocity with his family members. He had tremendous love for his mother, sisters and their families. This doctor, who went to the US with a specific objective and with a definite understanding to return to India, after accomplishing the said objectives, to start private practice in Guntur, was to abandon the idea hearing about the untimely, unexpected and unnatural demise of his beloved mother in 1981. It took quite a long for him to come out of that shock.

It was only after three years of his mother’s death that he came to India, in 1984, along with his family and stayed with us for a month and a half. Of course, thereafter he kept visiting us once in every two-three years. During those visits, we used to have long hours of conversations on various topics. He was such an avid conversationalist that he could relate himself with anyone in no time and make them feel at home with his cheerful disposition. He was very good at framing acronyms to explain his philosophy of life/ his faith in spiritualism. 

Once, he narrated his school experiences in Bandar that were pretty interesting to listen. Showing scars on his shoulder, he spoke about how he used to fetch water for his college-going sisters every morning from a distant well by keeping a bangy (a yoke, to whose both ends a rope-net is hanged to place the filchers filled with water) on shoulder. He fondly recalls his school teachers by their names … and narrates how he used to carry vegetables, etc. from Angalur for them… He warmly recalls the prayer that his history teacher—the teacher who is famously known after his fictional wife, Kantam, Munimanikyam Narasimha Rao—asked him to recite in the mornings: “Saraswati namastubhyam varade kamarupini / vidyarambham karishyami, siddhirbhavatu me sada …”

At times our conversation would veer to farming, which we both were attached to very longingly.  Even as a student of MBBS at AMC, Visakhapatnam, he used to attend to important farm activities. During his visit to India in 1999, I was to accompany him to Angalur, Masulipatnam and back to Guntur. While returning from Angalur, he stopped the cab on the road side under a Palmyra grove and showing me the fields that were a little away from the road, narrated how he as a student of AMC, every year in December, used to come to Angalur to get their paddy crop threshed, and even happily slept in the nights at the threshing flour in the company of a labor and brought paddy home securely. For, that was the only source of income for funding his education and other needs of the family as a whole.

On his every visit to India, he invariably used to visit his former professor of medicine, Dr Kodandaramaiah, at AMC, Visakhapatnam, perhaps to express his reverence for all the clinical knowledge, particularly the skill of differential diagnosis that he had imparted to him at KGH. In one such visit, as the professor narrated to him the events that led to his son’s death on his way to Chennai for medical aid, he seems to have at once exclaimed in wonder: “Professor-garu! What you said in KGH in our third year clinical-rounds is still ringing vividly in my ears: ‘If a patient complains about itching between the fingers, with no accompanying visible symptoms, your hand should immediately reach out for the kidneys.’ How is it, of all the people, you failed to diagnose the breakdown of the functioning of your own son’s kidney, that too, when he complained about an itching sensation continuously for a day or two”. Fighting back his tears and holding his hands, the Professor summoning enough energy to mutter: “Perumallu-garu … meekinka avanee gurthu unaayaa—you still remember all those lectures … you are such a good student, naaku andaruu inkolaa chepparu—but I was misled by others… it’s all quirk of fate … by the time it struck to my mind, it was too late.” This realization was indeed too late both in the case of his son and Dr Perumallu as well. Later, sharing this incident with me, he, being what he was, felt bad of his reminding him of his lectures and thereby multiplying his guilt-led anguish.

Ever since he took pre-matured retirement from the Cherry Hospital, Goldsboro, he had been calling me on phone on every alternate Sunday and we used to chat for hours together. Sometimes, he would take me on tour of Gray’s Anatomy… At times it would steer around cardiovascular diseases and the emergence of coronary collaterals, etc… It was such a pleasure discussing with him on such diversified topics, particularly psychology and psychiatry, for I was also interested in knowing a little more about human relationships, particularly, pathological relationships, transactional analysis, behaviour modification, etc., ... they were simply enchanting.

One Sunday, during such conversations suddenly, he landed on that short and burly neurophysiologist, Prof Brahmayya Sastry of AMC … Sharing his relation with him, he narrated how he got his sister who just got her PhD employed in his lab for undertaking research in one of his ICMR-aided projects. He had a high regard for him, not because he gave job to his sister but because he instilled in his young mind in the 60s how important it is to take physiology of a patient, particularly, the importance of Na, Ca, and K in maintaining cardiac stability, into consideration while evaluating his condition and prescribing medication. I too have an admiration for this Professor for he was one of the few Indian physiologists whose work was quoted in that bulky Physiology text of Medicos, which I read with interest as I was then fascinated about ACh, its synthesis, AChE, synaptic transmissions, neurotransmitters, etc. Having that at the back of my mind, I could hang on to the phone with interest listening to his talking a lot on the related issues. And, listening to him while he takes me on tour of such diversified topics was a sheer pleasure.  

The last few months had however turned out to be a little threatening. For, his health started deteriorating fast. Yet, he kept on sharing with me his philosophy of life, his varied interests, and his encyclopaedic knowledge of medicine that was intact till the end on phone but sensing his tired tone, I was to cut the conversations short. But he was as usual talking as though nothing had happened. But the very word ‘cancer’ was such a shuddering for me and my wife that it became difficult to put up long silences… used to eagerly look forward for his telephone ring on Sundays  … and as the days advanced with his experimentation with new drugs and listening to his getting in and out of hospitals for one correction or the other, and yet his speaking to us… always with a cheer in his tone… it was all nice to listen to him but deep in the heart, there was always a tug in the corner …

And finally, as the day came for the end of his journey from Angalur to America, everything was peaceful: On that fateful evening of 7^th December 2020 he,  in medical parlance due to cardiac arrest, passed away peacefully, “Unto the Shepherd’s arm!” while conversing with his younger daughter. All that I could now think of is: just to ruminate on his talks … on what he once told me, “We meet to part” … and silently offer my Śraddhānjali to him….

Wanna Develop ‘Self-Control’?

It is reported that due to the consumption of energy-dense food, sedentary lifestyle, lack of health care services and financial support, developing countries are facing high risk of obesity and the resultant consequences such as diabetes, and ischemic heart disease. In India, more than 135 million people are affected by obesity. Various studies have also shown that the prevalence of obesity is more among women than in men. Recent studies have also shown that globally, approximately 2.8 million deaths are reported as result of being overweight or obese (Rajeev Ahirwar & Prakash Ranjan, 2019).

 The essential part of obesity treatment is increased physical activity/exercise. It is said that people with overweight must undertake at least 150 minutes a week of moderate-intensity physical activity to prevent further weight gain. If, on the other hand, they wish to achieve significant weight loss, they must exercise 300 minutes or more a week. Though the regular aerobic exercise is the most efficient way to burn calories and shed excess weight, even moving around periodically in a day, helps in burning calories. About 10, 000 steps every day, is a nice goal to reduce weight gradually.

Along with it, a behaviour modification programme is also necessary. First, identify the current habits such as stresses, situations that are contributing to the weight gain, etc. Based on it, work out a plan of lifestyle changes required and importantly execute it. According to Centers for Disease Control and Prevention, USA losing just 5-10 percent of body weight will bring significant health benefits.

Interestingly, most of the over-weighing people, heeding to this advice, make plans for undertaking regular exercise to burn their excess calories. They all start with a great determination, but many of them, give it off half the way. It’s not that they aren’t motivated. They do know that overweight is harmful for them. They do know that their overweight is their esteem-crushing in a society in which thin is in. And yet, they fail in accomplishing their goal. And now the question is: why so many failures?

One immediate answer we all come up with is: these people lack ‘willpower’—will power to stay on course. And hence the failure. This is the commonest cause that we all identify behind all our failures. Now, what is this willpower? Simply put, it is nothing but putting off what one wants right at the moment in order to achieve a long-term goal. It is referred to as a resolve or self-control and involves a number of cognitive and behavioural characteristics:

• Willpower involves putting off what one want in the short-term to get what he/she wants in the long-term
• Its sustainability calls for conscious effort and also a significant investment of emotional and cognitive resources.
• It is the ability to maintain control to stay on course by resisting urges and guarding from temptations.

It’s needless to say that to accomplish anything in life we need to exercise ‘self-control’. Think about some of your past achievements of which you are indeed proud of, you would realize what an amount of hard labour you were to put on in pursuing it, the grit with which you were to resist all temptations to relax in order to stay focused on the goal and ultimately achieve it. The research of psychologists, Walter Mischel et al (1989) had shown that kids who were able to delay gratification had better grades, better academic test scores, and higher educational attainment. Later research by Angela Duckworth and Martin Seligman (2005) found that self-discipline played a greater role in academic success than IQ. Other researchers like Moffitt TE, et al (2011) have also found that people with higher self-control have better relationship skills, suffer fewer mental health problems, and have overall better physical health.

We all have this important element for success, ‘self-control’, albeit some have more of it while some are endowed with less of it. It is also true that even those who have a lot of self-control sometimes run out of it. For instance, people who have succeeded in accomplishing goals by dint of self-control, suddenly find themselves running out of it. For, self-control, like any other muscle, also suffers from fatigue. In other words, self-control, like any other muscle, can also be built up and strengthened with time and effort

Based on several studies, psychologists have found that ‘self-control’ muscle can be improved/strengthened by adopting a few strategies such as:

Use willpower muscle to strengthen it:

Your self-control muscle is like any other muscle of your body. If it is not used, it won’t get much exercise, and when it doesn’t get much exercise, it gets weak over time. On the other hand, if you get regular workouts by putting it to regular use, your self-control muscle grows stronger and stronger enabling you to achieve your goals. Mark Muraven in his 2010 paper published in J Exp Soc Psychol stated that “by practising small acts of self-control, overall self-control capacity can be increased”.

Pump it up:

Psychologists Mark Muraven et al (1999) say that by simply working on one’s self-control muscle regularly, one can strengthen one’s self-control significantly. This practice is no doubt, will be hard in the beginning, but if you hang on to it, it becomes much easier as the days roll on. And, as your muscle strengthens, it is sure to impact every aspect of your life for the better. Also remember, it gets exhausted by overuse. So, adopt right practice. Instead of completely spreading your will power on many goals at once, focus your will power muscle on one goal at a time to accomplish.

Improve your self-awareness:

In the normal course most of our choices are made on ‘autopilot’ mode, without knowing what is really driving them or what effect they will have on us. So, the first step in attempting to change our behaviour is to create ‘self-awareness’—the ability to recognize what we are doing as we are doing it. This awareness, the idea of our thought process, underlying emotions, and reasons for such acting, helps us in making better choices. Lack of self-awareness results in distraction, and distracted people are more prone to yield to temptations. That weakens self-control.

Use distractions:

When you are facing a temptation—whether it’s the desire to eat, sleep, spend, indulge in some other undesired behaviour—try looking for some type of distraction, such as the one used by the children in Mischel’s classic experiment where children closed their eyes or, turned their eyes away from the treat, to strengthen their will power to not to eat the treat.
 

Do it for Your-self:

Research indicates that when people do exercise to lose weight for their own reasons are more successful at it than when they undertake it for pleasing others. Internal motivation is always stronger in keeping you focussed on the goal than the external motivation. So, own it up: “I am exercising to lose weight for my own sake, for keeping myself healthy, for presenting myself more smartly”. This awareness and its assertion are sure to keep one glued to his/her chosen path.

Meditate:

Neuroscientists say that brain changes based on what we do continuously i.e. if we practice a certain behaviour, we are strengthening the neural connections for that behaviour, and because of which, our brain makes itself more accessible for that behaviour and hence that behaviour is likely to occur. It means, if we practice worrying, one gets better at worrying, for the brain region associated with that activity will grow denser. Similarly, if we practice concentration, we will get better at it. So, we can also train our brain for better self-control. And meditation is one of the best ways to achieve it. Indeed, meditation has a wide range of skills that are associated with self-control: attention, focus, stress management, impulse control, self-awareness, etc.

Maintain blood glucose levels: 

Recent research findings reveal that self-control is said to rely, at least partly, on the amount of glucose in bloodstream. Multiple studies revealed that a person’s blood glucose turns significantly lower after undertaking self-control-depleting tasks such as thought suppression, controlling attention, coping with the thoughts of death etc. In such circumstances, it makes sense to try a snack or a drink made with sugar. However, the best way to maintain a constant supply of blood glucose over a long haul is to eat protein and complex carbohydrates.

Be Enthusiastic:

Nothing is possible to accomplish without enthusiasm. For, enthusiasm is an essential element to keep one’s pursuit alive. None of the above can get operationalized unless one has unflagging enthusiasm to pursue the goal. Indeed, it is due to waning enthusiasm that most of the obese people are often found to give off their exercise half the way. That is what Lakshmana tells Sri Rama when he was lamenting at the absence of Sita in the hermitage:

“Śōkan vimuncārya dhrtin bhajasva sōtsāhatā cāstu vimārganesyāh¸
 utsāhavantō hi narā na lōke sīdanti karmasvatiduáskarēsu” (3.63.19)

— O noble prince, give up grief. Take courage. Show enthusiasm to search and find Sīta. Enthusiastic people will not get despondent in carrying out the most difficult tasks”.

So, it is evident from the foregoing that we can cultivate ‘self-control’, develop it and make it stronger (or, weaker) by regular workouts over time. Builders of self-control often say that it develops from trying and failing, trying and failing and in the process succeeding with small gains and staying focused on whatever being attempted with a little better each time. Therefore, what is needed is: ardent practice!

Delhi’s Climate Emergency Calls for a New Voice …

A year back, a 15-year-old girl sat outside the Swedish Parliament with a placard, “Skolstrejk For Klimatet” (School Strike for Climate). She was a lone figure then. Today, when she is blaming the elders for the inevitability of the climate catastrophe, the world is listening to her. The UK Parliament heard her saying, “You did not act in time.” In November, this diminutive teen called, Greta Thunberg, addressing a youth climate rally in Los Angeles, said: “The older generations are failing us. They are failing future generations, but future generations do not have a voice and the biosphere does not have a voice.” She then asked the rally, “Do you think they are listening to us?” When the crowd shouted loudly, “No”, she replied equally loudly, “Well, we will make them listen.”

And this has become a primal and a personal reason for Greta to forge this new path. In her recent address to delegates at the UN climate talks in Madrid, this 16-year old, who has been recently named Time Magazine’s person of the year, questioned the wisdom of the elders saying, “The biggest danger is not inaction. The real danger is when politicians and chief executives make it look like action, when in fact almost nothing is happening, apart from clever accounting and clever PR.”   

It is this kind of loud voice that is what is now needed to address India’s air-pollution crisis that is inflicting an incalculable toll on public health and economic growth. Many credible studies have attempted to quantify the impact of air pollution. A study carried out by IIT, Bombay estimated the cumulative economic cost for Delhi alone by 2015 was $6.4 bn. In 2016, Delhi residents experienced a deadly smog “with the particulate matter at 15 times higher than the safe-levels”. In 2018, the World Health Organization declared Delhi the most polluted city on the planet.

A long list of air-quality indicators is painting a grim picture. There remained many more yet to be quantified such as the extent to which the cognitive abilities of children growing amidst such air pollution are adversely effected. Similarly, we do not know the impact of loss of productivity of a person due to air pollution on the dependent family members. All this is a sure pointer towards the emergence of a greater threat from air pollution than what we have comprehended so far.

In the first week of November, Delhi was covered by toxic smog. It was so thick that flights were to be cancelled. Local government announced closure of schools. Indeed, it encompassed the whole of Indo-Gangetic plain. The position—AQI is exceeding 500—is getting worsened from year to year with the rise in consumption of dirty fuel by the ancient trucks, tractors, autos, cars and two wheelers that clog the newly laid out 4-lane roads, besides large scale biomass burning. Despite such a grave situation, no matching response to counter the menace of air-pollution is forthcoming from the government as well as the people. A recent survey carried out by EnvEcoLogic group in Delhi covering about 5000 individuals across the nine districts of Delhi region revealed how poorly the Delhiites are aware of the air pollution crisis and the regulations launched by the government to curb its ill-effects: 35% respondents do not consider air pollution in Delhi is an emergency; nearly 60% of respondents do not consider indoor air pollution in cities as a threat to life; and 50% of people are not aware that burning of garbage is banned and it attracts a penalty of   Rs5000.

That being the awareness of the people about the impending crisis—a ‘public health

emergency’—it is no wonder if the ‘command and control’ model adopted by our policymakers to handle the pollution-related problems failed in delivering the desired results. In other words, it tells us that mere framing top-down policies with a hope that people would simply tow government’s line will not give results till the people at the bottom are sensitized for a productive bottom-up contribution as well.

For instance, farmers in the rice-wheat cropping system of Punjab and Haryana states are known to burn an estimated 35 million tons of rice residues during October 15 to November 15 of every year in order to prepare their fields for the next wheat crop. But such burning, though cost-effective for farmers, causes air-pollution. Indeed, it is identified as one of the man-made causes for the worst air pollution that Delhi experiences. A mere top-down policy measure of penalizing the farmers for such burning simply failed in arresting this practice. For, a number of socioeconomic factors influence farmers’ residue management decisions: if a farm is owner-operated and if he owns large number of livestock he may resort to full residue removal by way of harvesting it for cattle feed; on the other hand, if the turnaround time between the harvesting of rice and the sowing of wheat is less, a farmer may resort to burning of the residue. So, unless policymakers come up with technological innovations to make rice residue removal and sowing of wheat crop less costly, farmers may continue to do what they have been doing all along.

That is where the need for leaders like that young Greta Thunberg is felt acutely to forge a movement, a movement that could address Delhi’s air pollution crisis effectively. For, such people-driven movements would be more powerful to bring in the desired behavioural changes in the society at large: scientists will address the underlying issues more diligently and come up with innovative answers to the problems; media would give vent to the voices of all the concerned by differentiating them into human frames, scientific frames, or policy frames, and policymakers would be better armed with requisite information to adopt right measures to mitigate the crisis, and people being aware of the underlying reasons for the ‘public health emergency’ actively participate in all the sustainable campaigns that are launched by the policy makers.