My school and the Duke of Edinburgh

Philip, the Duke of Edinburgh, is no more. The news of his death brought back memories of the Duke of Edinburgh scheme in our school. It involved participation in certain games, treks, camping and such as other activities. On completing the requirements, we would be given the Duke of Edinburgh of medal. It was quite a coveted medal and I remember that I just scraped through to receive one.  

The investiture ceremony was precided over by some foreign dignitary, a British of course, but I don't remember his name. Any person with a fair skin was next to God and a person who spoke fluent English, the Queen's English, was God incarnate. He gave away the medals, delivered an address, which, to be frank, I didn't follow due to his accent.

What remains etched in my memory is that a senior girl was to wrap a scarf around his neck, embroidered with the insignia of the Duke. She dutifully did that and to everybody's surprise and her utter embarrassment, the guest bent over and kissed her on her forehead. The whole school was scandalized. Nothing of this sort was ever known to us. The girl kept weeping for a very long time and the teachers had a tough time consoling her. I left with a very bad impression about British manners and mentioned this to Shashitai, my class teacher, the next day. She was very gentle and chose her words carefully to make me understand that people come from different cultures and have different ways of meeting and greeting. The gesture that I saw as having sexual overtones, was in fact that of appreciation and adulation. 

Sanjeevan vidyalaya did teach me a lot. 

☺️

Essay on atheism

 

India and the world's greatest religions series

Essay on atheism

By Dr. Shantanu Abhyankar 

Atheism disconnects itself from every kind of religious dogma. It denies god. The question follows, what kind of God? God is a nebulous term with varied interpretations. There are hundreds of religions and thousands of Gods. The layperson understands God, as an omnipotent, omniscient, omnipresent, immutable, eternal, ‘swayambhu’ person or spirit who is the source of all morality. Such noble qualities aside, it is commonly understood that this God answers prayers, is benevolent, sometimes short tempered, at times vengeful; but works by your side and for you, with enough prayers, etc.; where et cetera means a lot of things to a lot many people. It is this kind of God that atheists deny.  

 

Just like God there is a whole spectrum of atheists. It's not an all or none phenomenon. Agnostics do not rule out the presence of God but keep the chances to the minimum. The so-called ‘militant’ atheists say that God certainly does not exist. There are others who believe in ‘a power’ or God, not the ‘prayer-answering’ type- that set the rules, set those famed six constants, started everything off and now follow a hands-off policy. Then there are the ‘pantheists’, who look upon the universe itself as God. 

 

Only recently Dr. Richard Dawkins, the famous atheist, has given us the atheism scale. On a scale of 1 to 7; One- total belief in God and seven-sure disbelief and four is 50:50. This is not agnostic. Agnostic would be somewhere between 6.9 to 7; giving God just some benefit of doubt. They would rather be called ‘de-facto’ atheists. Dawkins ranked himself at 6.9; quipping, ‘absence of proof, is not a proof of absence.’ 

 

This scale is useful. Almost every atheist has travelled along this. Beginning as a firm believer, as taught by the cultural environment, growing out of this belief either through exposure to science, atheistic writings or thinking critically on one’s own. Only with great courage can some ‘come out’ and declare themselves as atheists. It isn’t very comfortable nor safe. There is the threat of ostracism from family, society and even death penalty in some countries. India prides itself in a long tradition of religious debate and discussion and strong undercurrent of atheistic philosophy. We know of Charvaka and his materialistic views. Hinduism accommodates a wide spectrum of beliefs.Thus one can declare oneself an atheist and still be accepted, even as a Hindu. 

 

Atheists keep asking for proof of God’s existence and the theists say, it is self-evident, needing no proof. The theists then challenge the atheists to prove the non-existence of the God entity. Belief is the default position, they say, and ‘absence’ a new assertion. The onus of proof squarely lies on the asserter. They also argue that they are right since majority carries the vote. Atheists will point out that extraordinary claims require extraordinary evidence and that, the God claim is certainly extraordinary. 

 

Such God debates are bound to be sterile and do not help us understand the contrasting conceptual framework. 

 

There is the naturalistic view of the world which presumes the universe to be a closed system, with nothing outside, influencing it. There are several questions this idea cannot answer. ‘Why does nature obey any laws at all?’, ‘How did conscious purposeful life arise from non-living matter?’ and so on.  If we don't know something it is better to accept that we don't know, rather than to imagine some answer. By imagining an answer, unsupported by proof, we discourage any further search for the real answer. This is the naturalistic point of view. 

 

The other is the supernatural view. It believes the universe to be divided in natural and supernatural realms which interact with each other. The fundamental truths about any realm are available in books and traditions. The obvious example of the supernatural spirit is ‘God’ who pervades, monitors and alters the universe. However there are nuances. The Abrahamic religions believe their God to be separate from the universe, whereas the Indo-Oriental traditions believe God pervading every living or non-living thing. What one sees and experiences as the material world is called Maya or Mithya. Beauty, goodness, patterns and order in the world is considered to be a manifestation of the divine presence.

 

The idea of naturalism is Spartan. It has minimal assumptions. As opposed to this, the supernatural idea of the world is baroque. It is embellished with several beliefs and assumptions and just about answers every question; like what exists? Why does it exist? How does it exist? How long will it exist? And so on. The answers to these come from ancient holy books: Tradition forbids any revision. Thus older the book, more authoritative and authentic it is.  

 

This particular approach of religion, of explaining everything without the need for evidence, is a butt of jokes. David Shotwell has famously said, ‘let's assume that each subatomic particle is inhabited by a dainty little gremlin, which maintains the existence of that particle by a continuous creative act and its instantaneous telepathic communication with others. By this means, they co-operate to produce the universe and its lawful behaviour!’ Bertrand Russell too mocked such an approach, quipping, ‘I know that there is a teapot orbiting the sun between the Earth and Mars; now prove me wrong!’ Given the technological limitations-this is obviously impossible.

 

  Rather than quibbling over approaches, the third school of thought suggests that science and religion are ‘non overlapping magisteria’, each equally important, equally valid and equally necessary. Why think in binaries; it need not be this or the other; it can very well be this and the other. Atheists counter by contradicting this as dodging all the challenges and simply moving the goal post.

 What qualifies religious beliefs and thoughts to be put on equal pedestal with science?  

 

The religionists readily can and do place their God in the gaps in knowledge. Such is not the way of science. For instance, if you keep on asking why, you soon reach a dead end and they say, ‘that is where god lies!”

For example, ‘why did it rain in Pune yesterday?’ 

‘The weather system caused it.’

‘Why the weather system?’

‘The earth's rotation, revolution, etc.’

‘Why is that?’

‘It's since the big bang’

‘Why is that?’

‘Following the big crunch.’

‘Why is that?’

‘Dunno!’

 

Now ‘that’ is what was caused by God!

 

It is rather impossible for God to exist for so many reasons. Firstly, God doesn't make his presence quite obvious. People say, God reveals himself to those who believe and pray. Belief; unquestioned belief! is a prerequisite. 

 

Divine impossibility can also be logically inferred by showing a pair of divine properties to be contradictory.  An omniscient God can predict the future but an omnipotent God can change everything that’s going to happen!  How does this fit? Can God make a rock so heavy that he himself cannot lift it? Though crisp and interesting, such logical repartees yield nothing. 

 

The strongest argument against religious thought and belief is the ‘problem of evil’. If God is good and stands by the good, why are there so many bad things happening? Different religions have answered this in different ways. Concepts like Satan, karma, God tests your mettle; have been invoked to get past this impassable question. 

 

Recently, scientists, sociologists, evolutionary psychologists are looking at the God idea from their lenses and explaining a lot of things. Sociologists have listed ideas common to all religions. Here is a very short list: 

·         A strong belief in supernatural powers, spirits and life after death.

·         A divide between ‘us’ and ‘them’; co-religionists are our own while others are inferior or infidels.

·         Rituals and rites of passage.

·         Omens. 

·         Music and dance.

·         Food taboos.  

·         Holy and tainted words, books, behaviours. 

·         Divine reward and punishment.

 

Since the God idea sprang from the human mind, studying our mental makeup through evolution, yields a lot of interesting clues. Evolutionary biology tells us that just as bodily traits decide whether you are selected in or out of the population; behavioural traits also decide your fate, evolving generation after generation. Certain thinking patterns and behaviours are evolutionary hallmarks of the human brain. These behaviours were extremely useful surviving in the African jungle but are useless or even a handicap in the modern concrete jungle. It is proposed that the God idea thrives on such age old, ingrained processes and hence can’t be readily got rid of.

For instance, we humans are pattern seeking animals. Given a few dots, we quickly connect them to conjure up a familiar figure. Our brains have evolved that way. Our ancestors on the savannahs would startle with a rustle in the grass. It could be the wind or a tiger. A striped pattern can be barely discerned in the thick grass but the brain quickly joins the dots and concludes that there is a tiger. It is prudent to take a distant, safer path than be the next meal for the big cat. Such pattern seeking, quick thinking mind has been selected in and we all have inherited it.

We have evolved with agency seeking minds. We simply believe that animate and inanimate world around us are agents having a mind and will of their own. This is called folk psychology. Spirits inhabit mountains, rivers, dead bodies; cyclones and earthquakes, are the result the wrath of gods. We readily believe all this. We believe, concurrence to be proof enough to conclude causation.  If an earache goes away after some sorcery or homeopathy, then credit readily goes to sorcery or homeopathy. If a deformed baby is born during an eclipse we blame the celestial shadow. Such mind-set favours the God belief. Theory of mind explains how our minds can guess what the other person is thinking ; that is walking in someone else's shoes. There are mirror neurons in our brains which make us feel the pain and pleasure of another. Sympathy and empathy thus pre-date the idea of religion.

Though there isn’t a God centre in our brain, the evolutionary framework of our mind provided a rich and fertile ground for the idea. The harvest has indeed been religion as a huge memeplex transmitted from generation to generation, from place to place.

There are several other factors. God and allied ideas spiralled as people started staying in larger groups. Social interactions in a band, of up to 150, are smoother. Fraudsters and free riders can be easily spotted and punished, not so with larger groupings. They need a more robust system. This is provided by the imaginary monitor- God. But the idea helped community building and building by the community too. The great pyramids could be built, only because everyone believed that pharaoh was god incarnate and his orders are mandatory. Religious ideas proliferated since they helped solidarity and won wars. Men have been summoned time and again for holy wars and have sacrificed everything for this cause.  Religion helped business too. Interaction became smoother between distant businessmen if they belonged to the same community. Even today cartels of traders, all from the same community are at work. Thus the proliferation of the god idea had to do with several factors.

Morality is often thought to be the exclusive domain of religion. Can one be good without God? Of course one can be. We do not draw our morality from God or any religious text, we just feel we do. No one can follow one’s holy book, word for word. We pick and choose from the wide variety of available teachings or reinterpret them to suit our times and happily believe that we draw our morality from religion. Tarkatirth Lakshman Shastri Joshi mustered evidence supporting Mahatma Gandhi's struggle against untouchability from the same texts which were quoted by his detractors. 

A godless morality is not only possible but desirable. The Indian constitution is a shining example of secular law, not drawing upon any religion. There is an upcoming science of morality. Certain moral behaviours are hard wired in our brains, through evolution.  Helping your kin and helping yourself by helping your kin, are evolutionary phenomena. Evolution is not just about survival through competition; in some aspects it is survival through cooperation as well. Evolutionary psychologists suggest that reciprocal altruism earns a good reputation and qualities such as loyalty, telling the truth, trustworthiness, and generosity help in building it further. Altruism too pre-dates religion.

Often the cruelty and pogrom by world’s well known atheists, Hitler, Stalin and Mao are cited as evidence against atheistic morality. The problem with fascism or communism, is not that they are too critical of religion but too much like religion. These ideas are dogmatic to the core and generally give rise to personality cults that are indistinguishable from cults formed in various religions and sects. Auschwitz and the soviet gulags are not examples of what happened when human beings rejected religious dogma but are examples of political, racial and nationalistic dogma. 

Atheists aren't averse to ‘spiritual experiences’. Of course this term is difficult to define but if it means enjoying love, music, poetry, nature, ecstasy, etc., the atheists do value these experiences and seek them actively. However they don't use the usual jargon connecting this to the divine. They are averse to unjustified claims about the nature of reality based on such experiences. Since most such experiences are subjective, atheists would rather wait for objective evidence. 

Finally a word about the Indian atheistic tradition; India has a long tradition of atheistic thought. Charvak (Baharspatya, Lokayat), the most ancient of such schools taught us that belief should be proportionate to evidence, that Vedas are nothing but human creation, rather than worrying about moksha, rebirth, heaven and hell, it is better to accept the ephemeral quality of life; that it is full of sorrow and pleasure, of torment and bliss, and get on with life. Self-abuse, wasting of resources and a perpetual, deeply negative attitude toward the world is no good.  No Charvak-ist text has survived. Traditionally critics would write a purva-paksha, survey the arguments they were refuting and then in uttara- paksha, present their own argument.  It is through such indirect means that we get a glimpse of Charvakian thought. We also have Jain and Buddhist traditions which denied god but stuck to concepts of heaven, hell, rebirth etc.  

But all said and done, though the majority of us believe that theists are in a majority, I have a different suggestion. All theists are atheistic towards all other gods but for their own! A Muslim denies the existance Christian God and vice versa. So, there are always more, ‘not believed in gods’; than those worshiped.  Atheists just let go of that one last God.  

 

 

Yes! I have good news!!

Yes! I have good news!!

Dr. Shantanu Abhyankar, Wai 

 

Wah Taj! The huge, majestic edifice in white marble stands shimmering.   I'm in a trance. What line and proportion, how simple yet elegant, what enchanting, heavenly beauty! One sees it again and yet again but always pines to visit again.

All of a sudden the spell is broken. Something stirs deep inside me and surfaces. The calm cracks. I think of Mumtaz Mahal and also of the several other mothers who died in labor. All of a sudden, I see the Taj, not as a timeless ode to love but as a memorial, a 'vrindavan',  to all those who died in labor including my grandmother's grandmother's aunt ('kaku').

A hardcore obstetrician like me can't be but become restless in the shadows of the Taj. 

Mumtaz Mahal died (1631), just 38, at Burhanpur, in her 14th pregnancy. Married at nineteen she bore 14 children in 20 years. The labor lasted for over a day. She delivered a girl child, later named Gauhar Aara Begum. Mumtaz died of severe postpartum bleeding. The Taj Mahal was built 22 years later.

Postpartum bleeding happens to be the commonest reason for maternal death to this date. Pregnancy induced hypertension, unsafe abortions and infections contribute as well. 

A tale of one such fatal sepsis had left an ugly scar on my grandmother's psyche.  Gladdened to know of my choice to become an obstetrician, my  demented, grandmother narrated it to me. It was her grandmother's aunt's, (Kaku's), tale. My great great grandmother's aunt, she was.

She delivered at home. It was arduous. She was shouting and struggling. She was crying and grunting. Trying to bear down all the while yet to no avail. The baby's head was stuck at the perineum. Midwives were summoned from the villages around. They couldn't manage it. The men gathered and failed. The closest hospital was 50 miles away and the fastest mode of transport was a 'chakada', (an ox cart drawn by one ox). But the ox was ailing and weak for any pulling. People tried massaging and rubbing up stronger contractions, they boxed, they pushed, they kicked the rotund tummy but the head remained stuck. Finally a midwife broke her bangles, and with a particularly sharp shard, gave a cut on the perineum. This worked. kaku delivered. But the baby was still born. The dead child was hurriedly buried in the backyard, placenta and all. Not a tear was shed. The relief of delivery overshadowed any grief about the stillbirth. Folks disappeared, men back to the farms and women to the kitchen. 

However, kaku was absolutely drained from the prolonged parturition. She started running fever the next day and chills and fever worsened over the week. Herbal fumes, homemade poultices, sitz baths and ointments for the wound were all tried. Holy ashes, black threads, amulets and incessant chanting of the 'shantipatha' were next. None was to enter the room without purifying one's feet by sprinkling gomutra (cow's urine), from a coconut shell placed on the 'umbara' (threshold), with a Neem twig.  But she quickly developed febrile delirium and became incoherent in her speech. A 'chunabhatti', kiln to generate fumes from slaked lime, was set up. The wound was fumigated with these fumes. The swinging temperature just worsened. The wound was now tense and angry red. From the septic tissue oozed a frothy, putrid discharge with an obnoxious odor. The stink engulfed the house and it became impossible to even approach kaku, forget nursing her wound. She was left alone. Puking  and peeing and defecating, all in that corner. Soon one night, her abdomen bloated up and she started bleeding.  The bleed stopped only with her breath. Kaku was no more.

Her mortal remains were consigned  to flames in the mango orchard. Uncle built a platform, placed a 'Tulsi vrindavan', (decorated garden pot specifically for the Tulasi plant; often nurtured in memory of a dear, revered person). The womenfolk bestowed on the place some pure and holy qualities.

Today 'Kaku's vrindavan', is a busy bus  stop on a highway. Across the street is a government hospital. A well equipped, well manned ambulance is always there, awaiting the next emergency. 

Inexplicably, my grandma seems to have struck a good equation with her grandma's aunt. They must have gelled well, been really close. This death was etched on my grandma's pubescent mind.

She initially believed kaku was lucky, for she died a 'saubhagyawati' (with her husband alive). But as the world around changed, she saw that  scarcity of every resource, extreme helplessness and absolute absence of medical know-how, were the causes of this misfortune. Causes more potent  than the stars. 

She carried this burden all her life and now she was passing it on to her, soon to be obstetrician, grandson. Hoping for him to help and heal women, so as to lighten it.

A woman dying in labor has been a source of the holy as well as the horrible. But sainthood and vrindavan are rare. Commonly, she is said to turn into a 'hadal' (pretty ghost). The banyan tree and the village well is her common abode. She's rarely seen before some ominous signs. One will hear the  bangles jingling, then a newborn's cry, followed by the smell of burning hair and then 'she' will appear; enchanting and ravishing in her looks. She will enamour the man she chooses. She's especially fond of tall, well built, handsome, young men.  Unless she wooes and enchants a man, her powers wane. Once she's had a firm grip on her paramour, she will come out with her true colors only to leave the man shattered. She's now just skin and bone. A mad look in her eyes, long loose hair, red 'lugade' (traditional 9 yard sari), forearms full of  green bangles and a huge red bindi on the forehead is now her 'display picture'. 

Such are the folk tales created by the patriarchal society. Note the thinly veiled catharsis of the manly longings, even when making a 'hadal' out of a woman.

 

Respect towards women ever was and still is, sparse. Respecting her wishes, considering her views about what ails her, wasn't ever factored in. True that the work pressure is demanding and doesn't allow for too much courtesy. However   isn't this a, part of routine work ethic? Health workers now received lessons about  'Respectful maternal care'. This helps. The women feel more secure and safe.

Unsafe abortion is another contributor to maternal mortality. India has the most patient-friendly  and women-centric abortion laws. Maternal deaths from unsafe abortions have thus declined though not eliminated. 

Pregnancy induced hypertension is a killer too. Described as, 'a secret, wrapped up in a mystery, engulfed by an enigma'; we know very little about its cause, prediction or prevention. Neither Ayurved nor any of the Indian languages have a specific word for it. Our ancestors failed to identify it as a specific disorder.  

Herein blood pressure rises, proteins leak through urine and there is bloating all over. The placenta, liver, kidney, brain, coagulation and fetal growth are affected. The fetus  fails to thrive and at times dies in utero. Sometimes the mother falls victim. Delivering the baby regardless of the gestational age and the chances of survival, is the final solution. Doctors still feel helpless against this marauder. 

India contributes a fifth of the global maternal deaths. But such numbers are redundant. We are the most populous nation, with 'India' and 'Bharat', rolled together and thus bound to score high on numbers. The maternal mortality ratio (MMR) matters. That's the number of maternal deaths per one lakh live births. 

And I have good news here!

Maternal deaths are rapidly becoming rarer and rarer. In 1990, 556 women died for every one lakh live births. Those many infants were left with just one parent. In 2014-16 the figure dropped to 130. Today, (2020), the figure is 97. The target is to bring it down to 70, by 2030.

Italy, Norway and Poland have contained MMR to single digits. Affable USA and the not so affable China hover around 19. Of course we are much ahead of Nepal (186), Bangladesh (173) or Pakistan (140). Congratulations!

The states with the highest MMR blame it on their usual woes. Poverty, illiteracy, blind faith, taboos, casteism, poor availability of doctors, drugs and equipment. Such conditions lead to a work ethic where referring a case to a higher center, rather than offering all possible aid, emerges as the best norm. A mishap elsewhere, is easier to explain and shrug off responsibility too.

 

Yet the target will surely be met. Uttar Pradesh, Bihar and Rajasthan started with a handicap but the MMR has been falling here too. Kerala reached 30, in 2020, much ahead of others and much beyond the target. Kerala now concentrates on the psychological problems in pregnancy. 

Mothers don't die due to medical negligence alone. Negligence happens at several levels and at each level negligence has decreased.  

Poverty has decreased and women are more respected. Child marriages are waning. The health services have reached far and wide. More and more women deliver under medical supervision, than at home. Blood banking services have expanded. Gone is the time when husbands scurried away at the mention of blood donation, for their bleeding beloved. Now several volunteers approach with their arms outstretched. Treatment of anemia has changed and its incidence is dropping. Small family size is now a given. Doctors have designed newer drugs, devised newer stitches,   newer balloons and developed newer surgical techniques, to arrest blood loss. There are newer antibiotics for germs old and new. Ambulances in far more numbers, far well equipped and well manned now stand ready in every nook and corner. The road length and quality has seen great improvement. Mobiles and the internet have made telemedicine a reality. Advice is now a video call away. Drones deliver drugs and blood too. Schemes like the Pradhanmantri Janani Suraksha Yojana have made a huge dent. Treatment, travel and food during confinement is now free…no wonder the picture is changing. The old order changeth yielding place to new.

When I visit Agra next, I will see the Taj Mahal as a tribute to love rather than as 'Kaku's vrindavan'

Doe rats, dame rabbits, female frogs and femme!!!

Doe rats, dame rabbits, female frogs and femme!!!

‘What is this test supposed to test doctor?’  

A portly, middle aged, mother of my teenaged patient, was almost irate. Her daughter lay on the examination table, curled up with her hands clutching her tummy.  

‘It tests for pregnancy!’ I answered in a calm voice.  

Her mouth gaped and just wouldn’t close; her uvula dangling mockingly. Finally she did manage her jaw and blurted, ‘she is mmmy daughter doc; she’s unwed, you know it, and why do you still order a pregnancy test? That’s outrageous!’

I am used to such diatribe. The scene repeats once or twice a year.  Usually I get the test done without the patient’s knowledge. She’s just told to ‘go and get the urine examined’, the words ‘for pregnancy’ are omitted. If I were to say it all, people such as this lady would never agree to the test. I just scribble UPT on the paper. This lady was smart enough to decipher the meaning and was incensed. With due sympathies for her moralistic indignation, as a doctor I am forced to play such tricks. Not testing can boomerang and spell doom. Everyone does this and each hospital has its own code word. One of my friend writes, CISC, meaning ‘check if she is carrying!’  

‘Do you really need that test?’ Mama.  

‘Unless otherwise proved, every ‘pregnantable’ woman is considered pregnant! That’s the dictum my teachers have taught me and my textbooks concur. I simply following that. Regardless of marital status or cohabitation, whether a divorcee or an abandoned woman, sterilized or otherwise, hubby vasectomized or otherwise, with copper T in situ or otherwise, everyone goes for the test at the slightest provocation. Many an accident is diagnosed and many a disaster averted due to timely testing and instant intervention.  

The lady calmed down, agreed to the test and left.  

Magically quick diagnosis is the power of the urine pregnancy test. Now a days patients don’t wait for me to prescribe the test, they come flaunting the strip. This is indeed recent. Just a few decades ago the diagnosis of pregnancy wasn’t all this simple. Diagnosing pregnancy in early months was even more challenging. Except for some honorable exceptions from the filmdom, no physician has ever been able to diagnose a pregnancy just by feeling the pulse!  

A certain diagnosis meant a wait for at least two to five months.  A visit to the doctor was mandatory. An embarrassing and uncomfortable internal examination would follow. Doctors often had a tough time coming to a diagnosis. Texts succinctly listed the causes of a bloated abdomen as, fat, flatus, fluid, faeces and foetus. But without a rotund enough belly, misdiagnosis was common.  

Amenorrhoea, morning sickness, milky discharge from the nipple, a bluish congested cervix and a soft bulky uterus were the earliest indicators of pregnancy. All of these were presumptive signs. The definitive signs were, perceptible foetal movements, foetal heart beat and of course birth!!!

You will find this rather amusing but this is how things stood for generations.  

In the eighties and nineties, home based pregnancy test became available in India and a silent revolution followed. The kit is now available in every drug store and ASHA and Anganwadi workers provide it for the asking. A few drops of urine at one end of the strip and lo behold, within minutes the strip lights up with one or two lines. A lone line means no pregnancy, two means a pregnancy and none means that the test isn’t working, you need to repeat it.

Early diagnosis of pregnancy has been an issue since ancient times. Had the test been was available to some of the leading

ladies of our epics; our cultural history would have been very different! Egyptian women would pee on wheat and barley. Sprouting wheat meant a girl, barley sprouts meant a boy and none meant no pregnancy. Such lore pervaded all cultures and now is the stuff of ‘Believe It Or Not’ columns.  

The line appears indicating the presence of HCG, a hormone, in the urine tested. HCG is formed by the baby’s placenta. It’s a chemical signal to the mother stimulating lots of metabolic changes favouring the baby’s nourishment. A woman, when pregnant, excretes plenty of this hormone through urine. The early tests to detect this hormone were too time consuming and complicated. Just a few decades ago such tests required animal sacrifice!  

Urine from the supposedly pregnant women was injected in doe rats (female rats) and a few days later they were dissected to check for ovarian stimulation, caused by HCG (Aschheim-Zondek test).   Friedman used female rabbits and devised a similar test. But the tests were costly, inefficient and therefore were used only under pressing circumstances. If there was a probable pregnancy, and the diagnosis was a must, and a turnaround time of two weeks was acceptable; it was then that the test was ordered. The greatest hurdle was keeping an animal house and the messy sacrifice. But there was no alternative. Later female frogs replaced rats and rabbits. The frogs laid eggs obviating the need for killing them and making the test a little cheap.  

India never saw these tests in common use. A senior colleague could vaguely recollect such a test being conducted at Haffkine Institute, Mumbai.  The cost and the infrastructure involved was prohibitive. We jumped from clinical examination to the simple urine test. Simple though it was it involved ten steps and a visit to the laboratory was needed.  Soon the home pregnancy kits were developed and these made a sea change.  

Pregnancy can’t be kept a secret. Sooner or later the diagnosis becomes obvious! But the DIY tests made early diagnosis easy, reliable and private. In fact in the privacy of the loo. Women now can decide whom to reveal the news to. They can decide upon the fate of the gestation. A positive test isn’t always a good news. It can be life shattering. Some eagerly await a positive result while some dread it.  

Considering the polar response to the result, the exact nature of the indicator on the strip was given a good long thought. Icons such as a sperm, a pregnant woman, and a smiling baby were all discarded. To some the angelic neonatal smile could appear sardonic. A plain, simple line was chosen.  It was left to the client to attach meaning to the result. Some suggested that flowery, bright packaging but it was thought that this will seem frivolous and rob the kit of its sober, reliable and clinical looks. The advertisements too focus on the secrecy, reliability and rapidity of diagnosis rather than smelly, unpleasant urine drops! Rapid, early and reliable diagnosis is indeed a boon. An unwanted pregnancy can be safely aborted, a wanted one can be nurtured. Certain drugs can be avoided, certain complications can be averted and doctors can guard against some.  

Take the case of this school girl for instance.

The test was done. It showed a positive result. The mother was left gaping.  

Ultrasound showed a pregnancy outside the uterus, in the Fallopian tube. The mother kept gaping.  

The tube had ruptured, and was spouting blood inside the abdomen.  

By the time we wheeled her in for an emergency surgery, the girl was already sinking. After a hasty surgery and five bags of blood she stabilised and survived.  

But for the pregnancy test, she would have died!!

Natural C-sections Available Here!!!

Natural C-Sections Available Here!!

Dr. Shantanu Abhyankar, 

Wai, Satara, Maharashtra, 

INDIA  

This was a week ago. I felt dejected, I was in deep despair, in the throes of depression, rather. Had never felt so low, melancholy, despondent and powerless. I am a man of stable mental makeup, taking luck, good or bad, in my stride. Or so I thought. Equanimity, as they call it. But this episode broke me. 

There was a patient, pregnant for the fourth time, almost term, with several complications related to her pregnant state. Her blood pressure was high, the sugars were swinging and platelets barely enough. She had had three previous C-sections. I was eyeing her as I perused the papers. I could sense she was fidgety. Her body language told me I was up against a challenge. Something like, ‘Doc, I will deliver with you, only and only if you guarantee a vaginal delivery!’ That would have been easy. I could politely tell her that it was impossible; getting rid of her and her problems at one stroke. 

But that was not to be. The lady said that she deeply ‘believed’ in nature and its powers. The world goes around due to these natural powers any way. Apart from those three C-sections, nothing unnatural had ever happened to her. In fact, through diligence and care, she had just not let it happen in any other manner.   

Thus she was ok about the C-section part but wanted me to perform a ‘natural’ C-section. This left me aghast, dazed and spent. I was conversant with various techniques of C-section, but was unaware of ‘natural’ C-section. I frankly told her so. She volunteered to define natural C-section as, ‘a C-section done sans artificial gadgets or drugs!’ 

‘All instruments I use are artificial, I am not conversant with art of opening the abdomen with a sharp flint stone’; I owned up my shortcoming. She instantly absolved me of the sin. ‘Instruments would do’, she said, ‘but you better be careful about the drugs. They should have no steroids, no hormones and no chemicals!!’ Here was a new twist.

I had now got over the initial prickliness and started enjoying the chat. The conversation now flowed naturally. ‘Ahem’, I began, ‘it’s like this, all hormones are chemicals but all aren’t steroids. But of course some hormones are steroids. However all steroids aren’t hormones but all are indeed chemicals. Some steroids do function as hormones. Finally whether hormone or no hormone, all steroids are chemicals and whether steroids or no steroid, all hormones too, are chemicals!!!’

I had made my kill. But perhaps I wanted to be doubly sure and continued in a philosophical baritone, ‘Let me assure you Madam, the prime reason that a woman is a woman and man a man is hormones; steroid hormones!’ I added with the flourish of James Bond.  

My strategy had worked. She sat stunned. She had the expression of a cat staring at the tangled mess of wool, of her own making. Then, for a moment, she contemplated whether to paw her whiskers or to whisker her paws. Finally she gave up and blurted, ‘So be it Doc, just try and keep the C-section natural, that’s all.’  

I felt like a hero from an ancient epic. Faced with weird curses, up against all odds; waiting for some quirk of fate or happy coincidence, to finally emerge victorious. I examined her, asked her to return after a week and sat scratching my head with both my hands.

I went over the steps of the C-section as I mused about making it natural. The patient initially receives injection Atropine. This is derived from the plant Atropa belladonna. Of course the one I use is synthetic but it mimics the original, natural agent. I thought my patient wouldn’t have any objections to this. Then the skin is cleaned with iodine. This is natural enough. And later comes a scrub with alcohol. Alcohol isn’t just natural, it’s ‘herbal’ too! 

Xylocaine is used for anaesthesia. This is artificial for sure. The natural alternative would be to knock her down with a hammer and rush through the procedure before she regains senses! This, I guessed, would be unwelcome, though natural.  

Once the baby is delivered the mother receives injections of Pitocin and/or Methergin. Pitocin (Oxytocin) is a hormone. I wondered if this was acceptable. But this is secreted in the human system. Once she is delivered, this hormone is going to surge forth from her Pituitary. A small additional dose from me shouldn’t matter. Methergin is a fungal derivative, natural and yes, in a way, herbal! The antibiotic would be a Penicillin. This is derived from that famous fungus, hence herbal and hence above objection. 

The jigsaw pieces just appeared to be automatically falling in place. Bliss it was.  

The uterus and other layers can be sutured with ‘Catgut’, an animal derived suture. The skin can be closed with linen. Usually I use better, newer and safer options but if ‘natural’ was the guiding principle, catgut and linen was the way to go. 

I had to strike off some routine drugs for Post-operative pain, for they were artificial. But Aspirin would do. It comes from Willow bark. Pentazocine would help too. This is an opium derivative. Natural, herbal and spiritual as well!!  

I would need ample Saline (intravenous fluids) too. But saline is just salt and water. Perfectly natural. 

Finally it dawned on me that anaesthesia, surgery, post-op care involved, perfect balancing of input and output, blood loss and transfusion, Oxygen and Carbon dioxide, water and electrolytes; and many more parameters. Thus this was indeed a ‘balanced C-section’.   

Add to this the fact that I will be removing the baby, placenta and the membranes in entirety. Leaving anything behind was hazardous. I have to remove all the ‘products of conception’. This would bring relief from pregnancy induced hypertension diabetes and the platelet deficiency. Thus my actions were to remove the ‘root cause’ of these ills. 

In short, mine wasn’t just a natural C-section but an herbal one too. Why just herbal? It was ‘balanced’ too. Balanced it was and it was removing the ‘root cause’…and since it was all this why not label it ‘holistic’? 

That resolved the conundrum. 

Overjoyed, I called up the sign board agency and said, ‘Need a new sign board which reads, ‘Natural C-Sections Available Here!’ Wait a bit, there’s a correction. Let it read, ‘Natural, Herbal, Balanced and Holistic C-Sections Available Here’!!

Dr Shantanu Abhyankar

9822010349

Wai, SATARA

Maharashtra

A mother dies.

 

 

A mother dies.

 

Dr. Shantanu Abhyankar,

Modern Clinic

Wai, Satara,

Maharashtra, INDIA

PIN 412803

Mobile no. 9822010349

                      

She was wheeled into my OPD and hauled over to the examination table and she passed away. She died, there and then. It was obvious that she was moribund. She was convulsing all the while, frothing at mouth, breathing noisily, sturterously but just about. There she laid pulse less, bloated all over, edematous from face to feet, with a nine month tense, shiny, belly bump in between.

She stayed somewhere beyond Mahabaleshwar, in the Tapola woods, across the Koyna backwaters. She had had her first convulsion early in the morning. She was carried in a hammock, the party trekking for two hours to reach the road. An hour’s wait by the roadside finally got them a Jeep. Driving up the ghat to Mahabaleshwar and then rolling down to Panchgani and Wai. It had taken seven hours to reach my hospital.

 

She died and I was left busy filling up the numerous papers and forms. Not that I objected. My objections were meaningless, anyway. Her death was now a part of a national problem. It was ‘Maternal death’. It will now be investigated. Reports will be sent up and queries will descend down. Papers will pile up. There will be meetings, inquiries and discussions. I felt sad and dejected. This death will pervade my thoughts all day long. I will keep seeing the unfortunate face.  Any death pains a doctor but this one was even more painful. A young mother dying just for want of timely intervention, one feels so helpless, so inadequate. This was her fourth gestation. What happens now to the three motherless children? How will they manage?

 

Four months passed and one morning I received a call from the district collector’s office.  A rude voice ordered me to be present for a meeting the next day at 11AM sharp. Eleven was the most inconvenient hour. I had scheduled appointments. It was impossible to reschedule them all at such a short notice. But I had to fall in line. One can’t fight with the powers that be.

I was uneasy but attended the meeting. An inquiry into such deaths was important. Not to point fingers but to identify the weaknesses in the system. 

She had sought help at three places on way and at all three she was simply asked to go ‘ahead’.

Her postmortem report wasn’t ready yet. The standard remark reading, ‘viscera preserved, opinion reserved’, stared back at me from the papers. This was another of routines. All the viscera are removed and examined in the forensic laboratory, just so that a homicide, an illness, or a poisoning isn’t missed. This wasn’t at all necessary in her case.  The cause of death was obvious from her history. The government doctor just wanted to be extra sure or rather wanted to shift the onus of the final opinion. 

She was carrying, had high blood pressure, which was neglected, had convulsed due to eclampsia and went into what’s called status eclapmticus, a state of continuous convulsions; she died. Eclampsia literally means a bolt of lightning. The disease strikes suddenly.  This is the consequence high blood pressure in pregnancy. She was seen by three doctors on way. All had made the same diagnosis. They were there too. I was the fourth.

A delayed post mortem report meant another sudden call from the district office, another get together, another meeting… missed appointments. I was about to vent my frustration with the system when it was announced that the civil surgeon will arrive late for the meeting but he has the report with him. That was a relief!  

Then began, what’s known as a, ‘verbal’ post mortem. I had certified the death but that was just incidental. I had had no chance to treat or even examine her. But this was my chance to have a ringside view of the government’s working.

Everyone was being cross examined. Who visited her hut? Which sub-center did her village fall under? Which ASHA worker was entrusted with the area? Why were the visits not made?

The district collector was a doctor who had later opted for the civil service.  He felt for the loss. With pointed questions, sparing no one, he was dissecting out the flaws in his own administration. Identifying every weakness in the chain, he was giving instructions, passing orders to overcome issues.

The deceased had not been seen for the past four months. The ASHA worker never visited her since.  According to her, ‘the people in the locality were uncooperative. They just ignored the health workers. The men are mostly drunk, are busy bootlegging and the women too are into moonshine.  The medical officer in-charge, a woman, too keeps away from this area. One is worried of hooligans and molestation. The ASHA worker prior to my appointment hadn’t reported a single pregnancy. I have dutifully registered her name. I have done my duty. Done what I could.’

The medical officer of the sub center, a woman, was asked as to why she wasn’t staying in the locality. ‘I don’t, but even if I were staying there, I was on leave on that very day.’ According to her, she had to rush back to her home town as her father in law suddenly took ill. She had evidence along with her. She produced  the old man’s death certificate and the recording of the phone calls with her superiors asking for emergency leave.

The patient was taken to a small dispensary on way. The elderly doctor manning this place was present. He had examined the patient in the Jeep. The relatives were put off because he didn’t even bother to record the blood pressure. ‘Feeling the pulse is enough for me to diagnose such a high blood pressure’, was his explanation. The collector looked at me. ‘Her GC (general condition) was very poor’, the elderly doc continued, ‘there wasn’t the need to waste time in recording the BP. I don’t have the necessary injections any way. I don’t keep them. There was no point of any detailed examination    since I don’t treat such patients. I simply asked to reach the hospital as soon as possible. I did my duty. I did whatever was possible.’

He wasn’t wrong. He had practiced ‘triage’. On a battle field one concentrates on the soldiers one can save and simply ignore the ones beyond help.  If one attempts to salvage all, then the ones better of worsen and die too. He had rightly sensed that this complication was beyond his abilities and refused the patient.

The next stop was a bigger, better, well equipped hospital. The doctor there had the necessary injections, knew the doses but hadn’t bothered to offer even first aid. He had just directed the patient to me. The collector was incensed. Here was a clear case of negligence. But the doctor was calm. He said, ‘by this time the patient had deteriorated further. She was in status, had vomited and aspirated the vomitus, there were audible rales all over her chest, her lips cyanosed and her breathing was barely discernible. In short she was sure to die within minutes. Any ‘first’ aid would be her last. I didn’t want to risk treating her!!!’ he said. The collector’s brow furrowed. The doctor explained, ‘the people from this locality had notorious reputation. Just a week ago they created a scene at the hospital next door. Their patient was well but disgruntled about the fees they had ganged up, threatened to shatter the place, paid nothing and left!’

There was an awkward silence. Finally the doctor continued, ‘The woman was to die despite my injections. But the relatives would have shattered my hospital blaming the injection for her death. At that hour neither your police nor your law would have been of help, would it? Had I been 100% sure that my hospital will not be targeted, I would have given the injection, knowing that it was futile to do so. But do you guarantee my safety? I have saved and protected my hospital, my staff, myself. It’s been four months since the death. You have summoned me today to explain my position. I have just this to say, I have safely delivered 160 women since. Saved as many women and children. I have done my duty. As far as could. Haven’t I?’

There was again an awkward silence. The civil surgeon hurriedly entered and joined the meeting. He cursorily asked for permission to speak and began narrating the report.  ‘It’s a fact that she was full term,’ he said, ‘it’s a fact that she had high blood pressure. It’s also a fact that she had convulsions. But, but, the convulsions were not due to high blood pressure!....The convulsions came and persisted due to a cerebral bleed!!....The bleed in the brain had resulted from trauma!!!...The trauma had resulted from her husband banging her head against a stone and… this punishment was meted out to her because the curry she had cooked was too bland!!!!’

A stunned silence descended on the room.

My cell shrieked rather outrageously. I had a call from my hospital. There was a woman, pregnant and convulsing. I took leave and started sped back to my place.

Breast is the best, or is it?

BREAST IS THE BEST, 

OR IS IT?

A relook at common wisdom

My blog for 

Population First

On BREASTFEEDING DAY

DR SHANTANU ABHYANKAR, WAI

Breast milk invigorates and nourishes the newborn like nothing else. It’s the baby’s first food, ensuring good health right into adulthood. Not surprisingly, almost every Bollywood hunk has sworn to the goodness of ‘Ma ka doodh’ on screen.

Successful breast feeding is the rich dividend following investment in the form of prenatal counselling, good   preparation, a positive attitude, institutional and government policies and time. 

‘Breast is the best’ and we need lactation friendly facilities even in public spaces. But there can be exceptions. The dictum, that all mothers should feed all babies, exclusively for six months, needs to be looked at again. Some special situations need to be factored in. 

Such blanket advice overlooks the physical, social and economic constraints of the mother. Ignorance or unwillingness to try hard enough aren’t the only reasons why a mother gives up breastfeeding. Many mothers need to get back to education/earning due to socioeconomic reasons. A six month sabbatical may not be affordable. If the cost of time invested, cost of giving up a job, refusing a promotion or a raise, is factored in, we will realize that breastfeeding isn’t cheap and certainly not free. 

Over glorification of breastfeeding can create guilt in the minds of women forced to give it up. Such mothers need positive support without guilt and judgment. Of course it is the mother's duty to feed the newborn but then it is the father's duty as well. It’s the responsibility of the family too. In fact just as not procreating is a personal choice, not breastfeeding can be a valid personal choice and needs to be respected. 

Low birth weight and preterm babies can accept only small aliquots of milk. They may not be able to cry aloud and are too weak to latch effectively and suckle vigorously. They need to be fed every hour or two, for the first three to four months. This leads to sleep deprivation and a lot of other physical and psychological challenges. In such situations, milk substitutes under medical supervision, may be given a thought. Insisting on exclusive breastfeeding can be counterproductive. The baby needs to be well fed and well-nourished; the source matters little in the face of such adverse conditions.

Babies larger than expected, especially those born to diabetic mothers, become too hungry, too soon. They may need supplement, till lactation is properly established.

Even normal babies often suffer hunger, for lactation is not well established in the first few days of life. The standard medical response to this is; ‘in the first few days of life, all that is secreted is all that the baby requires’.

However hunger in the early days of life can be life threatening. Emergency NICU admission with intravenous glucose may become necessary.  Long term neurological consequences of unrecognized low blood sugar can be disastrous. Hunger leads to excessive crying, lethargy, dehydration, convulsions, very low blood sugar and even sudden death.   

The mother is exhausted after labor and readily breaks into tears when she realizes that she is failing to feed the child. This inferiority complex and accompanying anxiety leads to reduced milk flow. Elderly mothers, comorbidities, cesarean section, a baby girl when a boy was expected; are stressful enough. A wailing toddler due to failed lactation is the last thing one would want. Lactation doesn't happen instantaneously. Suckling happens to be the strongest stimulus but suckling the child every two hours is easier said than done. Delayed onset of lactation is neither the mother’s fault nor the baby’s. 

Traditionally such problems have been tackled with wet nurses, cow’s milk etc.  Since milk powder is sterile and has known constituents in known proportion that closely match the composition of human milk, it’s preferred over animal milk.   Some cities now boast of milk banks, which is a good option too.

Breastfeeding is the obvious choice between sumptuous feeds and milk substitutes. However between reconstituted milk powder and emergency intravenous glucose; milk powder is obviously the better choice. Substitutes create problems because of improper reconstitution and unsafe water. We've made a lot of progress as far as safe drinking water is concerned. A properly constituted and safely prepared powdered milk is a good option. It is important to see that the baby is adequately and safely fed till the time lactation is well established. Once that happens, top feeds should be stopped forthwith.

Policies supporting milk substitute appeasing the market forces and abetting profiteering are bad but milk substitutes aren’t bad by themselves. Milk and milk substitute should be used judiciously according to their wishes needs and abilities off the mother and her family.