Tuesday, February 19, 2013

Apathetic Spectator Syndrome (ASS) - Do you have it?

I was a wrestling fan in my formative years and like most kids, I tried out those outlandish moves with my brothers & buddies. This was in spite of the repetitive "Don't try this at home" messages, which have recently been changed to, "Don't try this at home, school or anywhere else". Like those additions would make a LOT of difference convincing kids that didn't care in the first place! Now, you can either blame the kids for being stupid enough to imitate wrestlers, the parents for not monitoring them well enough or try to bring down the root cause - wrestling! And try they did. There were awareness campaigns, discussions by NGOs and people who had time to burn. For a while there, these nervous Nellies won - wrestling deserted the airwaves for some time. Us kids though, we carried on with our play, until one day, someone got hurt bad. No child was wheeled into the ICU, no police complaints were filed, but damn that hurt! One episode of pain & hurt is a better teacher than a thousand hours of lectures & awareness campaigns. 

TV is a powerful medium. We watch, assimilate, emulate and subconsciously draw knowledge from what we see. That is exactly the reason behind the aggressive anti-smoking campaign going on in India right now. You can't watch a movie or TV show without the statutory warning gliding across the screen. A lot of people argue that it takes away from the experience, that the immersive illusion is shattered when someone tries to blur out a cigarette or an "annoying" message flashes on screen. Directors and actors have criticized the policy saying that smokers will smoke, irrespective of whether the stars they adore do so. But, they underestimate the power of the very medium which they exploit. If even one person is disgusted enough by the cancer ridden lung images to quit, the campaign is a successful one & the ministry is justified. We take home a million messages from TV & movies - what is the difference between right & wrong, I need to work out to look as good, those clothes are in right now, I want to accomplished larger goals - So, what's the harm if one walks away knowing that smoking kills, even if the message is buried deep deep within his subconscious?

We watch, remember, & therefore we do. It's a simple concept that eludes Indian movie & TV writers when they portray doctors and medicine. I spoke of the immersive illusion of television earlier. I was watching a show where a neurosurgeon was attempting removal of a Meningioma with one of his arms in a cast & shoulder sling. Single handed Meningioma surgery aside, that idiot had the shoulder sling ON TOP of his sterile surgical gown! And then the illusion goes POOF! Indian TV shows have horrific production values most of the time & I don't see a lot of viewers complaining, or even realizing this dreadful oversight. So, it's understandable that they don't show ventilators, heart lung bypass machines, & have Casualty departments with just needles for equipment. But, it's how they portray the practice of medicine & doctors that irks me most. 

A world renowned neurosurgeon (Indian shows are fascinated by brain surgeons, I think) is called in to operate on a girl with a gunshot to the head. He flies in with much enthusiasm, but when the girl starts sinking, all he does is order the nurse to up fluids & starts massaging her palms and soles in an effort to revive her. Yes, that's what 12 years of neurosurgical training teaches us - something that grandmothers do when kids faint in the sun. Then there's the ubiquitous and classic, "The condition of the pregnant woman is very serious. We can either save the mother of the child. The family must decide soon". This is followed by a never ending ethical & philosophical discussion within the family about whom to save. I doubt there is a single obstetric condition which turns into an "either-mother-or-child" survival situation so dramatically. And even if there is, no doctor can ever ask that question! We are compelled by our ethical code & the law to save the mother irrespective of the risk to the fetus, having liberty to sacrifice the latter if required. Myth debunked! 

A man is shot while walking on the street and collapses in a pool of blood. As if out of thin air, a crowd surrounds him, but nobody moves closer than a few feet to help the man. As luck would have it, a medical intern was close by and she pleads with the crowd to help her take the victim to a hospital. The response was another archetypal Indian TV dialogue, "He's been shot, it'll be a police case. We can't move him until the police gets here." The intern then proceeded to reprimand the crowd, calling them - for lack of a better term - Pussies. And so the gunshot victim got taken to a hospital. This, I thought, is a great show. For those not residing in India, the scene I've described is a common occurrence in real life. The reason behind someone collapsing isn't always as dramatic as a gunshot, but the common man is hesitant to get involved in somebody else's crap. And their apprehension is partly understandable. Government hospitals lack manpower, so the onus of admitting and transporting the patient within the hospital often falls upon the person who brought them. The police is only just becoming more sensitive to these cases, & instances of good samaritans who have been made to needlessly wait and sign declarations by the police are common too. There is an acute need to let the common man know that their good deed will not be punished. There are of course, lives at stake here. But, while thoughts of Indian television having matured were only just forming in my head, the very next scene had a police officer admonishing the hospital dean saying, "It was obviously a police case. The intern must be punished. She should have waited for us to get there before moving him". Sigh. 

I think back to us kids imitating what we saw on TV & how we all got away with a few scratches, bruises & cuts. All seems well with our approach of mimicking what we saw on the telly & figuring out our limits. But, what of the boy who faces a life in prison after accidentally killing a girl while imitating a wrestling move? Or the boy who died imitating his favorite wrestler by diving off the roof?

There may not be any statistics to report  the number of people who died because bystanders didn't offer any help - let's term their affliction 'Apathetic Spectator Syndrome' or ASS, from watching too much TV. There are numerous stories which make me wish that TV would stop with these deceitful portrayals of what happens within hospitals or events leading up to an emergency admission. I shudder to think of the number of people who would apply what they see in these shows, in a very real time of emergency. It's about time TV woke up and realized its responsibility to create awareness extends beyond a puff of cancerous smoke. 

I'll leave you with one last story. A young doctor was riding his bike to college one morning, when for reasons unknown, he lost control and fell off at a busy intersection. Nobody came forward to help this man. The police brought him to the hospital where he worked and studied, estimating he lay on the asphalt for a good 20 minutes before they found him. An hour of relentless resuscitation attempts couldn't undo the damage of twenty minutes lying on the road alone. I wish more than ever, someone would have come forward to help that morning. 

Monday, February 4, 2013

The Evolution Of Fat People

For students of medicine and biology, this is a lesson in evolution and anthropology. For anyone with a BMI over 25, this is a factual, motivational tool. 

It all started with Balpreet Kaur, a Sikh girl going about her business at the airport. She wore a turban and as per her religious beliefs, did not rid herself of any facial or body hair. As luck would have it, someone with a cameraphone found her appearance humorous and decided to share the joke with others on Reddit. He posted the picture under the 'funny' category with the tagline, "I'm not sure what to conclude from this". It wasn't long before she knew that she was the subject of discussion, often ridicule, on the social network. Her response to her detractors & critics is nothing short of a modern example of poise & dignity - "By not focusing on the physical beauty, I have time to cultivate those inner virtues, and hopefully focus my life on creating change & progress for this world". You can read more here

Just a few weeks later, I read about Stella Boonshoft. Stella is a girl of voluptuous proportions, who has been ridiculed by her fellow students, trainers and men of interest, because of being overweight. She shared a semi-nude picture on Facebook to show the world how proud and comfortable she was with her over-weight body. It was her emotional outburst that accompanied the picture which caught my eye. My first response, one I'm sure a lot of you would have, was - More power to you! But, then I thought of Balpreet. The similarities between the two women at first glance are great. Both are strong women with character, both have been ridiculed or questioned for their external appearance, both used social media to their strengths and were lauded for it. That is where the similarities end.

It took a moment before I started wondering - Stella isn't that great after all. She's been over-weight, & from her account, since quite some time. While she's had ample opportunity to change her lifestyle, she's chosen to  chide society for setting unreasonable ideas of beauty. She's lashing out because she's had a rough childhood. I felt for Stella, nobody deserves to be ridiculed or made to feel inferior while growing up. Adolescence is a tough age for most of us, and it's especially tough when you're made out to be an easy target because of your appearance. But, as a smart, informed adult, she missed the point by a mile. While Balpreet is a strong woman of conviction, whose religious beliefs are exactly that - HER beliefs; Stella is just another person struggling with her weight. She's adamant about her body being only her concern, but the medical mind in me refuses to accept that. Somewhere down the line, her weight will be someone else's concern too - her doctor's. 

Society's norms of beauty keep changing. They follow cyclical trends & are fairly predictable. There was once a time in Victorian England where a woman's ankles were considered far too private to be exposed, her bosom though, was let free to feel the wind. Caucasians are obsessed with tanning to get that perfect golden brown skin tone, and the already golden brown Asians are obsessed with fairness creams. Society is way tougher on women - waxing, bleaching, hair removal are all painful procedures without much merit, and a woman's life is a continual struggle to please that handsome man in the commercials. Are fashion houses and beauty product labels being unreasonable? Most times. Each time the billboards are plastered with a woman who is excessively thin to begin with and then photoshopped to look like Aphrodite, they're being idiotic. But, their idiocy is matched only by their financial success, because we lap up these perverse standard of beauty. This is the problem that Stella was addressing.

Some standards though, have withstood the test of time. A sculpted, muscular body, toned physique, smooth, supple skin, flowing hair have never been out of style. There is but one universal standard of beauty in the world that hasn't changed in thousands of years - Athleticism. The pinnacle of human endurance, agility, strength and skill, these athletes represent all that is good about the human design. They represent health in all its glory, & are universally desirable. Desirability - that's all it comes down to eventually, desirability as a sexual partner. 

One of my professors often said, "The fact that Isaac Newton's sperm never met an egg is one of the greatest crimes against humanity!". He wasn't wrong. To paraphrase Tom Cruise from Jerry Maguire - Show me the GENES! We choose our partners, on the basis of so many factors - their looks, success, wealth, potential for growth. But, that's now. Far back when we were just scavengers in the forest, we chose on basis of strength and speed. One's external appearance mattered a lot then, as it does now, because it is a sensitive indicator of someone's health & their genetic quality. Scour through medical textbooks, and there're hundreds of signs visible externally that signify internal disease. So flawless skin, hair, ripped muscles are all desirable. Its all about having the best possible mix of genes. The desire to find a suitable sexual partner, procreate and have offspring that represent everything that's good about us, is universal. So, the next time you're questioning ideas of beauty, ask yourself how much of it has been created by corporate propaganda, and just how much are we all born with.

In a lot of ways, the reason we're fat is the same reason we orgasm. A lot of people thought that the orgasm was a fortunate blip, a physiological event that didn't serve much purpose. They couldn't have been more wrong. Just imagine if we didn't orgasm at all. Would we all still be having sex if it wasn't pleasurable? Somewhere down the line, we would give up on sex & the entire human race would be wiped out, being replaced by a species that enjoys sex. So, sex is enjoyable for a purpose. It is nature's way of telling us that we must survive as a species. We may all struggle to philosophically describe the purpose of life, but a biologist knows it already - Survival. Life exists - in strictly biological terms - to continue and perpetuate.

Getting back to my original statement - we're fat for the same reason we orgasm. Fat is the most efficient form of energy storage in the human body. Carbohydrate stores last us only for a few days and protein is far too essential to our body, therefore utilized for energy as a last resort. Back when we were evolving and food was scarce, we developed a taste for fatty foods. Evolution was smart that way, it made us love fattier meals so we would seek out and completely consume them. Energy storage was of paramount importance; one never knew how far the next meal would be. Those individuals that developed this rich taste, survived more easily than those that didn't. Move into the 21st century, and we've inherited the same fondness for fatty meals from our ancestors. Except food isn't as scarce anymore, but our appetites are just as insatiable. A quality that was meant to ensure our survival, is exactly the reason for millions of untimely deaths. Maybe, just maybe, evolution screwed up.

Obesity has been rampant since the past 50 odd years, and has mirrored our growth as a species.  This progress has brought an abundance of food, technological progress, medical innovation; But, it is exactly this progress which is the cause of our collective "growth".

Medicine has finally come of age. It wasn't until 1964 that we knew the link between smoking and lung cancer. Chemotherapy didn't give results until the 1970's. And AIDS was discovered only in 1981. The questions in medicine have shifted from 'What's causing this?', to a more reassuring, 'How can we treat it?'. We live in a spectacular time because important associations between diseases and causative factors have already been made. While we improve patient care with each passing day, there arises a greater drive and focus to reduce the number of patients altogether. Preventive medicine isn't a new buzzword, its the most important one. But, a culture of instant gratification means patients are more likely to demand a magic pill when ill, rather than take steps to prevent the illness in the first place.

Almost every obese patient I've counseled has said, "I just don't know what to do". As their doctor, one tries hard to make them see reason, to make them see the trouble that awaits. As their doctor, it's my job to tell them what to do. But, more often that not, the next time I see them - still just as obese - I listen to, "I just don't know what to do". Obesity is primarily a problem of the developed world, of the affluent classes. I do not say the problem lies with a lack of intelligence or information. That clearly isn't the case, most are extremely capable of assimilating the information we provide and acting on it. The problem is, they're careless and indifferent. Having foresight is what doctors are paid for,  but we cannot force it upon our patients; we can advocate, support, counsel and fight for our beliefs, but we cannot force them.

The age when patients religiously adhered to their physician's advice are long gone. The internet has disseminated information, both factual & fictional, in a way none of us anticipated. It is every patient's right to gather information about their health concerns and question their physicians about the same. It keeps us doctors on our toes. But, when your interpretation of the statistics does not match with ours, we urge you to trust our judgement. A figure of 1% risk seems trivial, until you become the statistic itself. I will not debate the prominence of environmental versus genetic factors in the surge of obesity, they both have an important role to play. Understanding the problem isn't enough, we need to acknowledge the magnitude of change required to overcome it and go about our business doing just that! Don't tell me that you don't know what to do. Such ignorance cannot be tolerated, your life depends on it.

Evolution doesn't ensure the survival of every being. 'Survival of the fittest' - As a high school student, I was perplexed with the choice of word - fittest. Darwin explained that survival isn't guaranteed to the largest, the strongest or fastest, but the one that is best suited to the present circumstances. He who adapts best, survives longest. The grandiose, seemingly indestructible dinosaurs were wiped out after the meteor hit because their large, inefficient, hungry bodies couldn't adapt to the scarcity of food that followed. Those that did survive, were the unlikeliest of creatures - mammals, which until then were a small, insignificant part of the ecosystem. And they rewrote the history of this little planet. Just as the dinosaurs, we're at the precipice of an enormous environmental change, that of relative abundance. Those that fail to change, fall prey to evolution ensuring only the fittest survive, in a literal sense. We need to stop dragging our feet because failing to adapt, means adding another chapter to the history textbooks. Except we don't need meteors anymore, when we've got McDonald's.

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