Ed Luce of Financial Times reviews Nandan Nilekhani's book on India. It is worth a read in its entirety. You should also see Nandan's own presentation here.
"Nandan' efforts", writes Ed Luce, "have produced one of the best and most thought-provoking books on India in years. Few Indian, or indeed Western, businesspeople would be capable of drafting such a dispassionate and self-critical account of their country’s prospects. And perhaps no other Indian public intellectual could write across so many disciplines -- politics, economics, finance, education, the environment -- with as much clarity and acuity."
"If only Indian policymakers would take note" Ed continues,"they could also turn the country’s relative lag when it comes to energy and the environment into an advantage. Nilekani offers many solutions, including building an integrated national gas grid to transport India’s growing supply of relatively clean natural gas. Many of the world’s most promising biotechnology and alternative-fuel entrepreneurs are Indians based in Silicon Valley. India could create a more attractive venture-capital sector to lure back more of its own scientists and entrepreneurs from abroad. Examples of potentially transformative Indian products that are already being developed at home include the $25 laptop and a carbon-positive electric car, which has a photovoltaic sunroof. Many more would be in the pipeline if India had a U.S.-style financial system for start-ups......India possesses the human know-how and natural resources to surmount its challenges. For example, it could devote much more agricultural land to growing biofuel crops such as switchgrass -- a move that would expand its energy stocks and relieve the country’s much-abused water table, which is being drained by water-guzzling crops such as rice and wheat. But reform would mean getting rid of the layer of bureaucrats and the groups of farmers who live off India’s lavish and grossly corrupt subsidy system......or good or for ill, the decisions of Indians will hold ever greater sway over the fates of other countries, including that of the United States."
"The solutions to India’s enormous problems" he concludes, " may not be around the corner, but they deserve very close attention. Nilekani’s book is an ideal place to start contemplating India’s great challenges and its no-less-breathtaking potential."
anil
Saturday, June 27, 2009
Friday, June 26, 2009
The Caregiver and the Patient
Some weeks ago I wrote a blog on the Caregivers Journey pointing out that there was nothing harder or more complex in life than to tend to a loved one whose life is slowly and painfully draining away and that the caregiver- be it the parent, spouse or sibling- face difficult and in some cases incredibly painful choices. It was a paean to the caregivers- all of them- and an ode to their patience, their compassion and their inspiration. But I had forgotten that the patients too carried terrible burdens which they rarely shared with their caregivers. They had a dual burden – besides dealing with the sickness, they also needed to think about the future when they would no longer be around but their caregivers would be.
This plight of the patient was brought home to me most poignantly recently when a friend of many years fell sick and in a space of a few months had to be hospitalized. He had been a robust, gregarious person with an active social life when he was stricken with neuropathy, an undiagnosed disorder that left him a shell of his previous self and full of pain and despair. I would often find him slumped in his chair holding his head in his hands complaining and fearing that his end was near and simultaneously worrying about his wife of five decades.
There is little in literature or research to help the patient negotiate these treacherous paths. Most focus on the patient’s ability to handle the shock and to help him through the next stages of depression and acceptance. Few help him to deal with the caregiver who normally keeps a stoic mien and cheerful exterior during this entire period. In the early days, it is normal for the patient to settle his temporal affairs, ensuring that his wife and family are well provided for, the wills written and all the other affairs taken care of. But as the time of sickness stretches out, it becomes more difficult to deal with the emotional impact of the impending separation.
There are no guidelines here. Many attempt to deal with it by retreating into silences or into religious ritual. Others attempt to create deliberately or subconsciously a schism with their loved ones so that their absence would be felt a little bit less. It is the same as many wives who create a quarrel with their husbands on the eve of their long journeys, hoping that their anger would tide over the early days of the separation. Some patients become rude and abusive towards their caregivers towards the end with the same objective. This friends wife came one day to us in shock and dismay , “ He says he wants a divorce”, she cried, “ We have been married for over 50 years and now he does not even want to see me.” It was hard for her to understand that this was not a request for a divorce lawyer but a plea from a drowning man trying his best to alleviate the pain that his impending absence would cause in her life. He was trying, in these rude ill chosen words, to help her cope with life after his departure.
The classic process by which people allegedly deal with grief and tragedy, especially when diagnosed with a terminal illness or catastrophic loss is described in the Kübler-Ross model of- denial, anger, bargaining, depression and acceptance. Denial is usually only the first stage and offers a temporary defense for the individual. This feeling is generally replaced with heightened awareness of situations and individuals that will be left behind after death. Once in the second stage of anger, the individual recognizes that denial cannot continue. But because of anger, the person is very difficult to care for due to misplaced feelings of rage and envy. Any individual that symbolizes life or energy is subject to projected resentment and jealousy. The third stage involves the hope that the individual can somehow postpone or delay death. Usually, the negotiation for an extended life is made with a higher power in exchange for a reformed lifestyle. Psychologically, the person is saying, "I understand I will die, but if I could just have al little bit more time...". During the fourth stage, the dying person begins to understand the certainty of death. Because of this, the individual often becomes silent, refuses visitors and spends much of the time crying and grieving. This process allows him to start to disconnect himself from things of love and affection. It is an important time for grieving for him that he needs must go through. The final stage comes with peace and understanding of the death that is approaching. Generally, the person in the fifth stage will want to be left alone.
The patient and the caregiver are both going through this cycle of grief. But what we have not understood is that many times they – the patient and the caregiver- are in different stages of the cycle. While one may have progressed to depression and then acceptance, the caregiver may still be in denial. My friend seemed to have progressed through the entire grief cycle in these three months. But his wife of over five decades, who was his prime caregiver, was still in the denial stage and found it difficult to adjust to his varying moods. The final stage of acceptance is not only for the patient but also for the caregiver. Denying that life will go on even after the patient has passed on is normal for the caregiver. But the double burden of the patient is to ensure that the caregiver will find that life does still exist and that she is a part of it. The real question is how to make others accept the inevitability that they now have to countenance and deal with?
As for the end, one would hope that we would celebrate a life and not only its end. It should be a special day when people, who loved a person, get together and celebrate his life, happily, and remember the person as he was...alive, and vibrant. It should be like the Irish wake, where there would be lots of food and plenty of drink to be consumed, people should come and socialize and remember the departed person's life. This should not be a time for tears but a celebration of his life. But it should also be simultaneously a renewal and a new life for the caregiver.
This plight of the patient was brought home to me most poignantly recently when a friend of many years fell sick and in a space of a few months had to be hospitalized. He had been a robust, gregarious person with an active social life when he was stricken with neuropathy, an undiagnosed disorder that left him a shell of his previous self and full of pain and despair. I would often find him slumped in his chair holding his head in his hands complaining and fearing that his end was near and simultaneously worrying about his wife of five decades.
There is little in literature or research to help the patient negotiate these treacherous paths. Most focus on the patient’s ability to handle the shock and to help him through the next stages of depression and acceptance. Few help him to deal with the caregiver who normally keeps a stoic mien and cheerful exterior during this entire period. In the early days, it is normal for the patient to settle his temporal affairs, ensuring that his wife and family are well provided for, the wills written and all the other affairs taken care of. But as the time of sickness stretches out, it becomes more difficult to deal with the emotional impact of the impending separation.
There are no guidelines here. Many attempt to deal with it by retreating into silences or into religious ritual. Others attempt to create deliberately or subconsciously a schism with their loved ones so that their absence would be felt a little bit less. It is the same as many wives who create a quarrel with their husbands on the eve of their long journeys, hoping that their anger would tide over the early days of the separation. Some patients become rude and abusive towards their caregivers towards the end with the same objective. This friends wife came one day to us in shock and dismay , “ He says he wants a divorce”, she cried, “ We have been married for over 50 years and now he does not even want to see me.” It was hard for her to understand that this was not a request for a divorce lawyer but a plea from a drowning man trying his best to alleviate the pain that his impending absence would cause in her life. He was trying, in these rude ill chosen words, to help her cope with life after his departure.
The classic process by which people allegedly deal with grief and tragedy, especially when diagnosed with a terminal illness or catastrophic loss is described in the Kübler-Ross model of- denial, anger, bargaining, depression and acceptance. Denial is usually only the first stage and offers a temporary defense for the individual. This feeling is generally replaced with heightened awareness of situations and individuals that will be left behind after death. Once in the second stage of anger, the individual recognizes that denial cannot continue. But because of anger, the person is very difficult to care for due to misplaced feelings of rage and envy. Any individual that symbolizes life or energy is subject to projected resentment and jealousy. The third stage involves the hope that the individual can somehow postpone or delay death. Usually, the negotiation for an extended life is made with a higher power in exchange for a reformed lifestyle. Psychologically, the person is saying, "I understand I will die, but if I could just have al little bit more time...". During the fourth stage, the dying person begins to understand the certainty of death. Because of this, the individual often becomes silent, refuses visitors and spends much of the time crying and grieving. This process allows him to start to disconnect himself from things of love and affection. It is an important time for grieving for him that he needs must go through. The final stage comes with peace and understanding of the death that is approaching. Generally, the person in the fifth stage will want to be left alone.
The patient and the caregiver are both going through this cycle of grief. But what we have not understood is that many times they – the patient and the caregiver- are in different stages of the cycle. While one may have progressed to depression and then acceptance, the caregiver may still be in denial. My friend seemed to have progressed through the entire grief cycle in these three months. But his wife of over five decades, who was his prime caregiver, was still in the denial stage and found it difficult to adjust to his varying moods. The final stage of acceptance is not only for the patient but also for the caregiver. Denying that life will go on even after the patient has passed on is normal for the caregiver. But the double burden of the patient is to ensure that the caregiver will find that life does still exist and that she is a part of it. The real question is how to make others accept the inevitability that they now have to countenance and deal with?
As for the end, one would hope that we would celebrate a life and not only its end. It should be a special day when people, who loved a person, get together and celebrate his life, happily, and remember the person as he was...alive, and vibrant. It should be like the Irish wake, where there would be lots of food and plenty of drink to be consumed, people should come and socialize and remember the departed person's life. This should not be a time for tears but a celebration of his life. But it should also be simultaneously a renewal and a new life for the caregiver.
Monday, June 22, 2009
Mysteries and Puzzles
Two articles recently have stimulated a discussion on the difference between mysteries and puzzles and why it is important to be clear about the distinction if we are to arrive at the right conclusions.
There's a reason millions of people try to solve crossword puzzles each day. Amid the well-ordered combat between a puzzler's mind and the blank boxes waiting to be filled, there is satisfaction along with frustration. Even when you can't find the right answer, you know it exists. Puzzles can be solved; they have answers.
But a mystery offers no such comfort. It poses a question that has no definitive answer because the answer is contingent; it depends on a future interaction of many factors, known and unknown. A mystery cannot be answered; it can only be framed, by identifying the critical factors and applying some sense of how they have interacted in the past and might interact in the future. A mystery is an attempt to define ambiguities.
Puzzles may be more satisfying, but the world increasingly offers us mysteries. Treating them as puzzles is like trying to solve the unsolvable—an impossible challenge. But approaching them as mysteries may make us more comfortable with the uncertainties of our age.
Osama bin Laden’s whereabouts are a puzzle. We can’t find him because we don’t have enough information. But we do know that he is somewhere and that he can be found. The right question here is finding the requisite information that leads to him.
Similarly during the cold war, much of the job of U.S. intelligence was puzzle-solving—seeking answers to questions that had answers, even if we didn't know them. How many missiles did the Soviet Union have? Where were they located? How far could they travel? How accurate were they? It made sense to approach the military strength of the Soviet Union as a puzzle—the sum of its units and weapons, and their quality. Initially puzzle-solving is frustrated by a lack of information. But eventually with the right information becoming available, the solutions are clear.
In contrast if you consider September 11th as a mystery, you have to wonder if the authorities asked the right questions at the right time. If you consider the motivation and methods behind the attacks of September 11th to be mainly a puzzle, then the logical response is to increase the collection of intelligence, recruit more spies, add to the volume of information. So in one case you want to improve the quality of your analysis, in the other the quantity of your information.
Sometimes, however, mysteries often grow out of too much information. Until the 9/11 hijackers actually boarded their airplanes, their plan was a mystery, the clues to which were buried in too much "noise"—too many threat scenarios. So warnings from FBI agents in Minneapolis and Phoenix went unexplored. The hijackers were able to hide in plain sight. After the attacks, they became a puzzle: it was easy to pick up their trail.Mysteries require judgments and the assessment of uncertainty, and the hard part is not that we have too little information but that we have too much.In the case of the Enron financial scandal, there was too much information available but no one had the skills to interpret the data. So rather than being a puzzle, it became a mystery.
Take another case- medical treatment. No matter how much patients may seek the clarity of a puzzle, healthcare, will remain largely a mystery. The goal of medicine is an absence—of illness and disease. But achieving that goal depends on many different factors. Tests are imperfect predictors of illness, and treatments interact or have side effects. Doctors base an initial assessment of a patient's health on propensity, as revealed by his or her medical history, and on diagnosis, determined through an examination. Dr Grootman ( How Doctors Think) alleges on average a physician will interrupt a patient describing her symptoms within eighteen seconds. In that short time, many doctors decide on the likely diagnosis and best treatment.If the doctor's initial assessment is of a high probability of disease, he orders more tests, which in turn refine that probability. Thus the route is one of seeking answers through more and more pointed questions and having the ability to ask the right questions.
Most discussions about energy, as well, treat it as a puzzle: so many million barrels of proven reserves in country X, production to "peak" in country Y at a particular date and so on. From a geological point of view, the puzzle perspective makes sense: any individual drill hole or field has so much oil. Yet energy futures are a mystery, not a puzzle. How much oil a given well can produce is not the same as how much oil is there: whether it makes sense to use secondary or tertiary recovery methods after primary methods no longer suffice depends on price. And beyond a single well, the factors multiply. How fast will the global economy grow? What new energy discoveries will be made? Which alternative sources will come on line at what price? This too requires a constant reappraisal of answers.
In essence a puzzle is mostly about the left side of your brain. It's a logical process of collecting data. Get enough data points and you'll be home free.Puzzles have straightforward answers. Collecting more data always helps you solve a puzzle, just as collecting more pieces of a real jigsaw puzzle gets you closer to assembling the picture. You know when you have solved a puzzle because all the pieces fit and the picture becomes completely clear.
On the other hand, solutions to a mystery live on the right side of your brain. The artistic, creative and non-logical side. Solving a mystery usually takes leaps of faith and judgment. Paradoxically sometimes adding more data to a mystery only serves to obscure the truth. In a murder mystery, such misleading bits of data are known as ‘red herrings’. Often mysteries do not have simple answers. Solving a mystery thus depends not simply on amassing data, but on developing an intelligent hypothesis and applying judgment to determine whether the hypothesis is correct. Mysteries contain inherent uncertainty.However rarely is a problem just a "puzzle" or a "mystery", usually it is both, requiring not just the careful analysis of existing information, but also the creation of new data.Thus the origin of life is a mystery to many, but to many scientists it is simply a puzzle requiring new information to resolve.
Finally to solve puzzles, you need the right data and information, to solve mysteries you need to ask the right questions.
There's a reason millions of people try to solve crossword puzzles each day. Amid the well-ordered combat between a puzzler's mind and the blank boxes waiting to be filled, there is satisfaction along with frustration. Even when you can't find the right answer, you know it exists. Puzzles can be solved; they have answers.
But a mystery offers no such comfort. It poses a question that has no definitive answer because the answer is contingent; it depends on a future interaction of many factors, known and unknown. A mystery cannot be answered; it can only be framed, by identifying the critical factors and applying some sense of how they have interacted in the past and might interact in the future. A mystery is an attempt to define ambiguities.
Puzzles may be more satisfying, but the world increasingly offers us mysteries. Treating them as puzzles is like trying to solve the unsolvable—an impossible challenge. But approaching them as mysteries may make us more comfortable with the uncertainties of our age.
Osama bin Laden’s whereabouts are a puzzle. We can’t find him because we don’t have enough information. But we do know that he is somewhere and that he can be found. The right question here is finding the requisite information that leads to him.
Similarly during the cold war, much of the job of U.S. intelligence was puzzle-solving—seeking answers to questions that had answers, even if we didn't know them. How many missiles did the Soviet Union have? Where were they located? How far could they travel? How accurate were they? It made sense to approach the military strength of the Soviet Union as a puzzle—the sum of its units and weapons, and their quality. Initially puzzle-solving is frustrated by a lack of information. But eventually with the right information becoming available, the solutions are clear.
In contrast if you consider September 11th as a mystery, you have to wonder if the authorities asked the right questions at the right time. If you consider the motivation and methods behind the attacks of September 11th to be mainly a puzzle, then the logical response is to increase the collection of intelligence, recruit more spies, add to the volume of information. So in one case you want to improve the quality of your analysis, in the other the quantity of your information.
Sometimes, however, mysteries often grow out of too much information. Until the 9/11 hijackers actually boarded their airplanes, their plan was a mystery, the clues to which were buried in too much "noise"—too many threat scenarios. So warnings from FBI agents in Minneapolis and Phoenix went unexplored. The hijackers were able to hide in plain sight. After the attacks, they became a puzzle: it was easy to pick up their trail.Mysteries require judgments and the assessment of uncertainty, and the hard part is not that we have too little information but that we have too much.In the case of the Enron financial scandal, there was too much information available but no one had the skills to interpret the data. So rather than being a puzzle, it became a mystery.
Take another case- medical treatment. No matter how much patients may seek the clarity of a puzzle, healthcare, will remain largely a mystery. The goal of medicine is an absence—of illness and disease. But achieving that goal depends on many different factors. Tests are imperfect predictors of illness, and treatments interact or have side effects. Doctors base an initial assessment of a patient's health on propensity, as revealed by his or her medical history, and on diagnosis, determined through an examination. Dr Grootman ( How Doctors Think) alleges on average a physician will interrupt a patient describing her symptoms within eighteen seconds. In that short time, many doctors decide on the likely diagnosis and best treatment.If the doctor's initial assessment is of a high probability of disease, he orders more tests, which in turn refine that probability. Thus the route is one of seeking answers through more and more pointed questions and having the ability to ask the right questions.
Most discussions about energy, as well, treat it as a puzzle: so many million barrels of proven reserves in country X, production to "peak" in country Y at a particular date and so on. From a geological point of view, the puzzle perspective makes sense: any individual drill hole or field has so much oil. Yet energy futures are a mystery, not a puzzle. How much oil a given well can produce is not the same as how much oil is there: whether it makes sense to use secondary or tertiary recovery methods after primary methods no longer suffice depends on price. And beyond a single well, the factors multiply. How fast will the global economy grow? What new energy discoveries will be made? Which alternative sources will come on line at what price? This too requires a constant reappraisal of answers.
In essence a puzzle is mostly about the left side of your brain. It's a logical process of collecting data. Get enough data points and you'll be home free.Puzzles have straightforward answers. Collecting more data always helps you solve a puzzle, just as collecting more pieces of a real jigsaw puzzle gets you closer to assembling the picture. You know when you have solved a puzzle because all the pieces fit and the picture becomes completely clear.
On the other hand, solutions to a mystery live on the right side of your brain. The artistic, creative and non-logical side. Solving a mystery usually takes leaps of faith and judgment. Paradoxically sometimes adding more data to a mystery only serves to obscure the truth. In a murder mystery, such misleading bits of data are known as ‘red herrings’. Often mysteries do not have simple answers. Solving a mystery thus depends not simply on amassing data, but on developing an intelligent hypothesis and applying judgment to determine whether the hypothesis is correct. Mysteries contain inherent uncertainty.However rarely is a problem just a "puzzle" or a "mystery", usually it is both, requiring not just the careful analysis of existing information, but also the creation of new data.Thus the origin of life is a mystery to many, but to many scientists it is simply a puzzle requiring new information to resolve.
Finally to solve puzzles, you need the right data and information, to solve mysteries you need to ask the right questions.
Sunday, June 21, 2009
Father's Day thoughts
Most people remember their parents or close friends through some vignettes which have remained stuck in their memories for ever and ever. It is an accumulation of such memories that seems to define our view of their entire life. Rarely if ever do we sit down to think about placing these memories in some context to obtain a coherent and complete view of their entire life. It is these vignettes that define them for us. So it is for fathers.
When asked about their earliest memories of their fathers, many of us would have difficulty in defining them in some details. But ask us if we remember some action or thought that has defined our relationship with them, most would easily find quite few incidents from their lives.
So as I reflected on my fathers life- he has now been gone almost fifteen years- a few vignettes stand out which in a certain sense define him for me. Of them the earliest was when I asked why he became an economist. We were at that time discussing the profession I would soon choose for myself.It then came out that when he was a young student, he heard Pandit Nehru, the charismatic leader of the Indian National Congress urge all Indians to fight for complete independance on the banks of the Ravi river in 1930. He urged students to help rebuild the country and said that the country would need economists and engineers to lay the foundation for the future.That speech inspired the deep idealism in him to chose economics as his profession. ( Incidentally, mine was engineering).
Another defining incident was when I found that he chose to resign from his job as the editor of the premier economic magazine in the country, The Eastern Economist, rather than bow to the wishes of the proprietors to push the preferred policies of the industrialist who also owned the magazine.He was willing to lose his job rather than compromise on his principles.Since we had a comfortable house close to his office and we had to shift to hutments built for soldiers during the war, the change was a considerable downgrade at that time even though he found a job with the government.
A third incident occurred when I led a student movement against the powerful professor and head of the hostel at IIT, Kharagpur in the first year of my engineering course.Dr Muthanna was a tough as nails administrator who tolerated no dissent and when a group of students organized to challenge his policies and his executive abilities, he was not only outraged but he took action. Unbeknownst to me, he wrote a strong letter to my father threatening that he may be forced to expel me from the institute for my union efforts. My father sent him an equally uncompromising reply pointing out that Dr Muthana needed to deal with the students more sympathetically and that in any case it was unlikely that his son would be participating in any activities that were not right and justified. He had complete faith in my judgment and sense of responsibility.My father did not send me a copy of this letter -- indeed I found out about it only years later when I was going through his papers.
A few years later I won a scholarship to go to Berkeley but found that I had not enough money for the air ticket. I was busy selling off all my possession in order to raise the necessary funds when I received a letter from my father containing a check for the air fare.
We came to a parting of ways for a brief while when I got married and he refused to accept the choice I had made. We remained distant and silent for almost seven years- you see he had passed on his uncompromising attitude to me as well.He was a man of strong and rigid convictions. It took my children to bring him around finally which he did.And we were to spend his last years as close as we had been all our lives before the break.
And then a few years later, he was diagnosed with colon cancer requiring a major operation. I was then posted in Bombay and would fly down to be with him after the operation while my brother looked after him. He was to live with this for almost fifteen years till he died. But during this period I rarely heard him complain about the pain or the restrictions that these operations placed on him. We would discuss everything under the sun except his medical pains and problems. His courage and stoicism remained with him till the end and he refused to give up.
When I look back, it is these vignettes which define for me his life--his idealism, his courage of his convictions, his stoicism in face of pain, his love for his family and his willingness to confront life without compromise.
When asked about their earliest memories of their fathers, many of us would have difficulty in defining them in some details. But ask us if we remember some action or thought that has defined our relationship with them, most would easily find quite few incidents from their lives.
So as I reflected on my fathers life- he has now been gone almost fifteen years- a few vignettes stand out which in a certain sense define him for me. Of them the earliest was when I asked why he became an economist. We were at that time discussing the profession I would soon choose for myself.It then came out that when he was a young student, he heard Pandit Nehru, the charismatic leader of the Indian National Congress urge all Indians to fight for complete independance on the banks of the Ravi river in 1930. He urged students to help rebuild the country and said that the country would need economists and engineers to lay the foundation for the future.That speech inspired the deep idealism in him to chose economics as his profession. ( Incidentally, mine was engineering).
Another defining incident was when I found that he chose to resign from his job as the editor of the premier economic magazine in the country, The Eastern Economist, rather than bow to the wishes of the proprietors to push the preferred policies of the industrialist who also owned the magazine.He was willing to lose his job rather than compromise on his principles.Since we had a comfortable house close to his office and we had to shift to hutments built for soldiers during the war, the change was a considerable downgrade at that time even though he found a job with the government.
A third incident occurred when I led a student movement against the powerful professor and head of the hostel at IIT, Kharagpur in the first year of my engineering course.Dr Muthanna was a tough as nails administrator who tolerated no dissent and when a group of students organized to challenge his policies and his executive abilities, he was not only outraged but he took action. Unbeknownst to me, he wrote a strong letter to my father threatening that he may be forced to expel me from the institute for my union efforts. My father sent him an equally uncompromising reply pointing out that Dr Muthana needed to deal with the students more sympathetically and that in any case it was unlikely that his son would be participating in any activities that were not right and justified. He had complete faith in my judgment and sense of responsibility.My father did not send me a copy of this letter -- indeed I found out about it only years later when I was going through his papers.
A few years later I won a scholarship to go to Berkeley but found that I had not enough money for the air ticket. I was busy selling off all my possession in order to raise the necessary funds when I received a letter from my father containing a check for the air fare.
We came to a parting of ways for a brief while when I got married and he refused to accept the choice I had made. We remained distant and silent for almost seven years- you see he had passed on his uncompromising attitude to me as well.He was a man of strong and rigid convictions. It took my children to bring him around finally which he did.And we were to spend his last years as close as we had been all our lives before the break.
And then a few years later, he was diagnosed with colon cancer requiring a major operation. I was then posted in Bombay and would fly down to be with him after the operation while my brother looked after him. He was to live with this for almost fifteen years till he died. But during this period I rarely heard him complain about the pain or the restrictions that these operations placed on him. We would discuss everything under the sun except his medical pains and problems. His courage and stoicism remained with him till the end and he refused to give up.
When I look back, it is these vignettes which define for me his life--his idealism, his courage of his convictions, his stoicism in face of pain, his love for his family and his willingness to confront life without compromise.
Monday, June 15, 2009
The will to succeed
One of the hardest tasks that aspiring youngsters in India face is entry to the prestigious Institutes of Technologies. Every year 230,000 from all over India compete for barely 5,000 seats in the country's seven IITs. With only a one in forty chance of getting in, the fact that one training school managed to get all of its 30 students selected for the IIT’s is an amazing feat, made even more amazing by the fact that all of them came from the poorest families from the poorest state in the country. Thereby hangs a tale worth telling.
Anand Kumar trains the poorest students in Bihar for entry into the prestigious Indian Institutes of Technology’s. A brilliant mathematics student himself, but from a very poor background, he could not take up admission at the Cambridge University even with a fellowship as he had no means to provide for his basic expenses. But he was determined to keep the tradition of Ramanujam, the mathematics wizard, alive and started giving lessons to the street children and those in the slums in the early 90s. He started the Ramanujam School of Mathematics in the mid-90s.
The task that Anand has taken on himself is to ensure that not a single underprivileged boy or girl in Bihar (with exceptional intelligence) is deprived of an opportunity to get ahead because of their lower social and economic condition. Anand is acutely aware from his own history that to be born with an extraordinary intelligence quotient alone does not guarantee success in life. He remembers all too clearly that he had to fight hard just to get to use the superior mathematical ability he realized he possessed early on in life. "The Super 30 was born with this idea in mind," explains Anand.
Super 30 is a highly ambitious and innovative educational program which hunts for 30 meritorious talents from among the economically backward sections of the society and shapes them for India's most prestigious institution – the Indian Institute of Technology (IIT). The normal group comprises wards of brick kiln worker, rickshaw puller, landless farmer, roadside vendor and the likes. During this program students are provided absolutely free coaching, lodging and food. This initiative is funded by the money Anand Kumar earns from his coaching. Founded in 2003, 18 students made it to the IIT’s in the founding year. The number rose to 22 in 2004 to 26 in 2005 to 28 in 2006 and 2007 and up to 30 in 2008 and 2009. Yes that’s correct! In the last two years, the super 30 boasts of a cent percent record with 30 out of 30 students coming through. The training school's feat is even more amazing in a state where more than two million children are out of school, and the literacy rate is a shameful 47%.
How did they do it?
The students come here to attend classes from Patna and also from faraway villages and make the journey every day by bus, on bicycles or even on foot. Those who stay in the hostels are provided free food and lodging. Each year 6,000 young boys buy the application form for Rs 60 from the Institute and submit it in the hope of making it to the Super 30. Candidates then take three separate admission tests to determine IQ, administered in ascending order of difficulty. Of the 500 short-listed initially, 30 eventually make it to the core group. The basis of the selection is that the candidate has to be from an underprivileged background. These are the poorest but with the most powerful minds. The training that lasts a year is rigorous and almost monk like in its intensity. But there are no drop outs from the program.
When you are trapped in a situation where you know you have the intelligence to conquer the world but you are crushed in by your circumstances, you'll do anything to break free. This is perhaps the true secret behind the success of Super 30. This and the commitment of a single individual to an idea.
Anand Kumar trains the poorest students in Bihar for entry into the prestigious Indian Institutes of Technology’s. A brilliant mathematics student himself, but from a very poor background, he could not take up admission at the Cambridge University even with a fellowship as he had no means to provide for his basic expenses. But he was determined to keep the tradition of Ramanujam, the mathematics wizard, alive and started giving lessons to the street children and those in the slums in the early 90s. He started the Ramanujam School of Mathematics in the mid-90s.
The task that Anand has taken on himself is to ensure that not a single underprivileged boy or girl in Bihar (with exceptional intelligence) is deprived of an opportunity to get ahead because of their lower social and economic condition. Anand is acutely aware from his own history that to be born with an extraordinary intelligence quotient alone does not guarantee success in life. He remembers all too clearly that he had to fight hard just to get to use the superior mathematical ability he realized he possessed early on in life. "The Super 30 was born with this idea in mind," explains Anand.
Super 30 is a highly ambitious and innovative educational program which hunts for 30 meritorious talents from among the economically backward sections of the society and shapes them for India's most prestigious institution – the Indian Institute of Technology (IIT). The normal group comprises wards of brick kiln worker, rickshaw puller, landless farmer, roadside vendor and the likes. During this program students are provided absolutely free coaching, lodging and food. This initiative is funded by the money Anand Kumar earns from his coaching. Founded in 2003, 18 students made it to the IIT’s in the founding year. The number rose to 22 in 2004 to 26 in 2005 to 28 in 2006 and 2007 and up to 30 in 2008 and 2009. Yes that’s correct! In the last two years, the super 30 boasts of a cent percent record with 30 out of 30 students coming through. The training school's feat is even more amazing in a state where more than two million children are out of school, and the literacy rate is a shameful 47%.
How did they do it?
The students come here to attend classes from Patna and also from faraway villages and make the journey every day by bus, on bicycles or even on foot. Those who stay in the hostels are provided free food and lodging. Each year 6,000 young boys buy the application form for Rs 60 from the Institute and submit it in the hope of making it to the Super 30. Candidates then take three separate admission tests to determine IQ, administered in ascending order of difficulty. Of the 500 short-listed initially, 30 eventually make it to the core group. The basis of the selection is that the candidate has to be from an underprivileged background. These are the poorest but with the most powerful minds. The training that lasts a year is rigorous and almost monk like in its intensity. But there are no drop outs from the program.
When you are trapped in a situation where you know you have the intelligence to conquer the world but you are crushed in by your circumstances, you'll do anything to break free. This is perhaps the true secret behind the success of Super 30. This and the commitment of a single individual to an idea.
Sunday, June 14, 2009
The great US health care debate
Recent months have seen the start of the great debate on health care in the US. The facts are clear- there are 45 million uninsured citizens in the richest country in the world which has the highest cost of health care but with no comparable favorable outcomes.
While the next months will see this debate demagogued no end, as a user of this health care system, some things are absolutely clear- there is absolutely no incentive in this system for anybody to control costs. Not the patient, who is insured, and has no interest in shopping for more cost effective care, just the best that is available; not the doctors, who on the plea of malpractice suits possibilities, order all or any tests that may be relevant ( and some of them performed by facilities owned by them); not the hospital which is happy to provide all the latest facilities needed or not as it adds to their profits; not the pharmaceutical companies who encourage new and costlier drugs rather than the generics on the plea of need of funds for further research, not the insurance companies who are happy to pass on the costs of all this health care to the public through rapidly rising premiums. In short everybody is happy with their health care - that is till the bill comes due!
An average US family today pays $ 500-1000 per month in health premiums, deductibles, medicines etc. I could see a tip of why after I insisted on a bill from the hospital I had just returned from -- in the itemized bill, an aspirin pill was charged at $ 8-- yes $ 8-- and a simple blood sugar test at $ 25 while every intern who visited me even for five minutes along with the team was happy to add his wages to the bill leading to a cost of almost $ 2500 per day for a simple stay in the hospital without any major surgeries. Clearly it is a system where the costs have run amok. In some ways it is the inverse of the major damage caused in the recent collapse of the financial system- in the financial system people were investing other peoples money in the riskiest of bets; in the medical health care system, people are spending other peoples money to ensure the least possible of risks for all operations !
But is that the way it should be ? Are there any no alternatives that offer cost effective care? Atul Gawande in a recent article pointed out that indeed there are alternate ways of delivering health care that are both effective and less costly since they align the patients well being with cost effective care. He does that by describing two operating systems in different parts of the country to make his point.
McAllen is in Hidalgo County, Texas has the lowest household income in the country but it has one of the most expensive health-care markets in the country. In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns. The place has virtually all the technology that you’d find at Harvard and Stanford and the Mayo Clinic, and yet there’s no evidence that the treatments and technologies available at McAllen are any better than those found elsewhere in the country. Nor does the care given in McAllen stand out for its quality. Medicare ranks hospitals on twenty-five metrics of care. On all but two of these, McAllen’s five largest hospitals performed worse on average. McAllen costs Medicare seven thousand dollars more per person each year than does the average city in America. But not, so far as one can tell, because it’s delivering better health care.
Why is this so? It seems that doctors here order unnecessary tests just to protect themselves. Doctors were racking up charges with extra tests, services, and procedures- patients in McAllen got more of pretty much everything—more diagnostic testing, more hospital treatment, more surgery, more home care.Thus the primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine. This is further exemplified in its newest hospital in the area which is physician-owned which has a reputationfor aggressively recruiting high-volume physicians to become investors and send patients there. Physicians who do so receive not only their fee for whatever service they provide but also a percentage of the hospital’s profits from the tests, surgery, or other care patients are given, providing physicians an unholy temptation to overorder. It was clear that a few leaders of local institutions in this area took profit growth to be a legitimate ethic in the practice of medicine and a medical community came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers.
On the other extreme of medical practice lies the Mayo Clinic model, which is among the highest-quality, lowest-cost health-care systems in the country. Its core tenet “The needs of the patient come first”—not the convenience of the doctors, not their revenues is as different from McAllen as is possible. The doctors and nurses, and even the janitors, sit in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. Decades ago, the Mayo Clinic recognized that the first thing it needed to do was to eliminate the financial barriers. It thus pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their own personal income. Mayo promoted leaders who focussed first on what was best for patients, and then on how to make this financially possible. They focussed on rooting out problems like poor prevention practices, unnecessary back operations, and unusual hospital-complication rates- on patient well being rather than on profit maximization.
When you look across the spectrum from the Mayo Clinic to McAllen—and the almost threefold difference in the costs of care—you come to realize that there is a battle being waged for the soul of American medicine. But a choice must be made. Whom do we want in charge of managing the full complexity of medical care? We can turn to insurers (whether public or private), which have proved repeatedly that they can’t do it. Or we can turn to the local medical communities, which have proved that they can. But we have to choose someone—because, in much of the country, no one is in charge. And the result is the most wasteful and the least sustainable health-care system in the world.
It is interesting that the solution most opposed by the right wing ideolouges actually embraces the twin principles of market competition and individual choice !
While the next months will see this debate demagogued no end, as a user of this health care system, some things are absolutely clear- there is absolutely no incentive in this system for anybody to control costs. Not the patient, who is insured, and has no interest in shopping for more cost effective care, just the best that is available; not the doctors, who on the plea of malpractice suits possibilities, order all or any tests that may be relevant ( and some of them performed by facilities owned by them); not the hospital which is happy to provide all the latest facilities needed or not as it adds to their profits; not the pharmaceutical companies who encourage new and costlier drugs rather than the generics on the plea of need of funds for further research, not the insurance companies who are happy to pass on the costs of all this health care to the public through rapidly rising premiums. In short everybody is happy with their health care - that is till the bill comes due!
An average US family today pays $ 500-1000 per month in health premiums, deductibles, medicines etc. I could see a tip of why after I insisted on a bill from the hospital I had just returned from -- in the itemized bill, an aspirin pill was charged at $ 8-- yes $ 8-- and a simple blood sugar test at $ 25 while every intern who visited me even for five minutes along with the team was happy to add his wages to the bill leading to a cost of almost $ 2500 per day for a simple stay in the hospital without any major surgeries. Clearly it is a system where the costs have run amok. In some ways it is the inverse of the major damage caused in the recent collapse of the financial system- in the financial system people were investing other peoples money in the riskiest of bets; in the medical health care system, people are spending other peoples money to ensure the least possible of risks for all operations !
But is that the way it should be ? Are there any no alternatives that offer cost effective care? Atul Gawande in a recent article pointed out that indeed there are alternate ways of delivering health care that are both effective and less costly since they align the patients well being with cost effective care. He does that by describing two operating systems in different parts of the country to make his point.
McAllen is in Hidalgo County, Texas has the lowest household income in the country but it has one of the most expensive health-care markets in the country. In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns. The place has virtually all the technology that you’d find at Harvard and Stanford and the Mayo Clinic, and yet there’s no evidence that the treatments and technologies available at McAllen are any better than those found elsewhere in the country. Nor does the care given in McAllen stand out for its quality. Medicare ranks hospitals on twenty-five metrics of care. On all but two of these, McAllen’s five largest hospitals performed worse on average. McAllen costs Medicare seven thousand dollars more per person each year than does the average city in America. But not, so far as one can tell, because it’s delivering better health care.
Why is this so? It seems that doctors here order unnecessary tests just to protect themselves. Doctors were racking up charges with extra tests, services, and procedures- patients in McAllen got more of pretty much everything—more diagnostic testing, more hospital treatment, more surgery, more home care.Thus the primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine. This is further exemplified in its newest hospital in the area which is physician-owned which has a reputationfor aggressively recruiting high-volume physicians to become investors and send patients there. Physicians who do so receive not only their fee for whatever service they provide but also a percentage of the hospital’s profits from the tests, surgery, or other care patients are given, providing physicians an unholy temptation to overorder. It was clear that a few leaders of local institutions in this area took profit growth to be a legitimate ethic in the practice of medicine and a medical community came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers.
On the other extreme of medical practice lies the Mayo Clinic model, which is among the highest-quality, lowest-cost health-care systems in the country. Its core tenet “The needs of the patient come first”—not the convenience of the doctors, not their revenues is as different from McAllen as is possible. The doctors and nurses, and even the janitors, sit in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. Decades ago, the Mayo Clinic recognized that the first thing it needed to do was to eliminate the financial barriers. It thus pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their own personal income. Mayo promoted leaders who focussed first on what was best for patients, and then on how to make this financially possible. They focussed on rooting out problems like poor prevention practices, unnecessary back operations, and unusual hospital-complication rates- on patient well being rather than on profit maximization.
When you look across the spectrum from the Mayo Clinic to McAllen—and the almost threefold difference in the costs of care—you come to realize that there is a battle being waged for the soul of American medicine. But a choice must be made. Whom do we want in charge of managing the full complexity of medical care? We can turn to insurers (whether public or private), which have proved repeatedly that they can’t do it. Or we can turn to the local medical communities, which have proved that they can. But we have to choose someone—because, in much of the country, no one is in charge. And the result is the most wasteful and the least sustainable health-care system in the world.
It is interesting that the solution most opposed by the right wing ideolouges actually embraces the twin principles of market competition and individual choice !
Thursday, June 11, 2009
The human heart
The cockroach has survived every civilization known to man.Evolution has favored cockroaches above human beings, at least when it comes to the functioning of the heart. A cockroach’s heart will continue to beat even when one of its chambers has failed; in similar circumstances, a man will die. Thus the lowly cockroach is at the heart of successful research by scientists who are developing an artificial heart. Using the roach’s heart as a model, the new prototype promises to be much cheaper and more reliable for implantation in humans than models currently in use.
The key to the new heart involves the insect’s unique breathing system. The cockroach is blessed with thirteen blood-pumping chambers while humans only have four. When a chamber fails in a human heart, it usually leads to a fatal cardiac arrest but in a cockroach with its 13 chambers,linked like a string of sausages, it can keep pumping even if one breaks down!A cockroach’s heart is a tube that runs the length of its body. As each chamber contracts, the blood within is pumped to a higher pressure. Each successive chamber increases the pressure. A human heart, by contrast, has four chambers. Two of these pump blood to the lungs, where it picks up oxygen, then the other two pump this oxygenated blood throughout the body. One of these four chambers—the left ventricle—contracts most strongly to pressurize the blood.
The artificial hearts developed so far have mostly mimicked human ones. The first devices, developed in the 1950s and 1960s, were large machines placed on trolleys next to the patient and attached by tubes. Modern artificial hearts are less cumbersome, but they are still rather unwieldy because they use compressed air to pump the blood and are powered by heavy batteries. They are used temporarily, usually for a few days or weeks, until a real heart is available for transplant.
Instead of trying to mimic the action of the left ventricle, Dr Guha’s design uses a multi-step approach borrowed from the cockroach. His device, made from plastic and titanium, is the same size as a human heart but with five chambers arranged like the layers of an onion. Each chamber acts in succession to increase the pressure of the blood. The contraction of each chamber is controlled by a motor driven by bulky batteries. "Our model is based on the cockroach system, where we build up the pressure in smaller steps. So even if one chamber fails, a person can still live. This model does not stress the other components (pumping elements) and there is less stress on the blood cells”, says team leader Professor Sujoy Guha.The artificial heart, named TAH ( total artificial heart) is being tested on goats, with human trials scheduled for next year. If these are successful, the device could be on the market in three to five years.
The multi-step approach makes this artificial heart much cheaper to build than those that use compressed air to pump the blood. Dr Guha says it would cost $2,000-2,500 about thirty times cheaper than the present models.
I read these reports with great pleasure for a number of reasons. First the research was led by an Indian. Secondly it was done in India. And even more importantly the work was done at the Indian Institute of Technology at Kharagpur, my alma mater. I graduated from this IIT in 1961 and visited the institute only last year- as the institute had decided to honor me as a Distinguished Alumnus. But the most inspiring news was that the leader of the team was Sujoy Guha who graduated with me in 1961! Wow indeed.
On a more personal note, I spent the better part of 2007 in Johns Hopkins hospital in Baltimore being evaluated for a heart transplant.I was not approved for a human heart transplant, but perhaps the cockroach inspired TAH of Professor Guha would be the replacement! To have your heart redesigned by your own classmate- how cool is that!
The key to the new heart involves the insect’s unique breathing system. The cockroach is blessed with thirteen blood-pumping chambers while humans only have four. When a chamber fails in a human heart, it usually leads to a fatal cardiac arrest but in a cockroach with its 13 chambers,linked like a string of sausages, it can keep pumping even if one breaks down!A cockroach’s heart is a tube that runs the length of its body. As each chamber contracts, the blood within is pumped to a higher pressure. Each successive chamber increases the pressure. A human heart, by contrast, has four chambers. Two of these pump blood to the lungs, where it picks up oxygen, then the other two pump this oxygenated blood throughout the body. One of these four chambers—the left ventricle—contracts most strongly to pressurize the blood.
The artificial hearts developed so far have mostly mimicked human ones. The first devices, developed in the 1950s and 1960s, were large machines placed on trolleys next to the patient and attached by tubes. Modern artificial hearts are less cumbersome, but they are still rather unwieldy because they use compressed air to pump the blood and are powered by heavy batteries. They are used temporarily, usually for a few days or weeks, until a real heart is available for transplant.
Instead of trying to mimic the action of the left ventricle, Dr Guha’s design uses a multi-step approach borrowed from the cockroach. His device, made from plastic and titanium, is the same size as a human heart but with five chambers arranged like the layers of an onion. Each chamber acts in succession to increase the pressure of the blood. The contraction of each chamber is controlled by a motor driven by bulky batteries. "Our model is based on the cockroach system, where we build up the pressure in smaller steps. So even if one chamber fails, a person can still live. This model does not stress the other components (pumping elements) and there is less stress on the blood cells”, says team leader Professor Sujoy Guha.The artificial heart, named TAH ( total artificial heart) is being tested on goats, with human trials scheduled for next year. If these are successful, the device could be on the market in three to five years.
The multi-step approach makes this artificial heart much cheaper to build than those that use compressed air to pump the blood. Dr Guha says it would cost $2,000-2,500 about thirty times cheaper than the present models.
I read these reports with great pleasure for a number of reasons. First the research was led by an Indian. Secondly it was done in India. And even more importantly the work was done at the Indian Institute of Technology at Kharagpur, my alma mater. I graduated from this IIT in 1961 and visited the institute only last year- as the institute had decided to honor me as a Distinguished Alumnus. But the most inspiring news was that the leader of the team was Sujoy Guha who graduated with me in 1961! Wow indeed.
On a more personal note, I spent the better part of 2007 in Johns Hopkins hospital in Baltimore being evaluated for a heart transplant.I was not approved for a human heart transplant, but perhaps the cockroach inspired TAH of Professor Guha would be the replacement! To have your heart redesigned by your own classmate- how cool is that!
Sunday, June 7, 2009
Pakistan on the brink
Pakistan is close to the brink, perhaps not to a meltdown of the government, but to a permanent state of anarchy. Even as most Pakistanis have concluded that the Taliban now pose the greatest threat to the Pakistani state since its creation, the president, the prime minister, and the army chief have, until recently, been in a state of denial of reality. One can therefore expect a slow, insidious, long-burning fuse of fear, terror, and paralysis that the Taliban have lit and that the state is unable, and partly unwilling, to douse.
The Taliban have taken advantage of the vacuum of governance by carrying out spectacular suicide bombings in major cities across the country. Having won Swat, the Taliban have made clear their intentions to overthrow the national government. Although the group has no single acknowledged leader, it has formed alliances with around forty different extremist groups, some of them with no previous direct connection to the Taliban. Moreover, the Afghan Taliban have become a model for the entire region. The Afghan Taliban of the 1990s have morphed into the Pakistani Taliban and the Central Asian Taliban and it may be only a question of time before we see the Indian Taliban.
Ahmed Rashid in his latest article paints a grim picture of the impending failure of Pakistan and its likely repercussions.
The Taliban have taken advantage of the vacuum of governance by carrying out spectacular suicide bombings in major cities across the country. Having won Swat, the Taliban have made clear their intentions to overthrow the national government. Although the group has no single acknowledged leader, it has formed alliances with around forty different extremist groups, some of them with no previous direct connection to the Taliban. Moreover, the Afghan Taliban have become a model for the entire region. The Afghan Taliban of the 1990s have morphed into the Pakistani Taliban and the Central Asian Taliban and it may be only a question of time before we see the Indian Taliban.
Ahmed Rashid in his latest article paints a grim picture of the impending failure of Pakistan and its likely repercussions.
Empathy anyone ?
During the past few weeks, ever since Obama announced his pick for the supreme court justice, there has been one word at the center of all discussions-- empathy. It was important for people to have empathy as they preside in the supreme court. But what is empathy ? It is the ability to be able to feel someone else's pain and be able to walk in their shoes?
From the time of Adam, the one thing that men have never learnt is to empathize with their better halves- witness the tomes written on " understanding women". But once in a while, a writer gets it just right. Here is Dana Jennings on his brief life as a woman..
From the time of Adam, the one thing that men have never learnt is to empathize with their better halves- witness the tomes written on " understanding women". But once in a while, a writer gets it just right. Here is Dana Jennings on his brief life as a woman..
" As my wife and I sat on the couch one night this past winter, reading and half-watching the inevitable HGTV, I started sweating hard and my face got so fevered and flushed that I felt as if I were peering into an oven. I turned to Deb and said, “Man, I’m having a wicked hot flash.” And she said, “Me, too.” Then we laughed. You laugh a lot — unless your hormones are making you cry — when you’re having menopause with your wife."
Dana was taking a course in hormonal therapy as part of his cancer treatment and one of the side effects was menopause like symptoms."The side effect that surprised me most were the hot flashes" he writes, " — not that I got them, I was expecting that, but by how intense they were. They often woke me in the middle of the night and made me sweat so much that I drenched the sheets. In midwinter I’d walk our miniature poodle, Bijou, wearing shorts and a T-shirt. I sometimes felt as if Deb could fry eggs on my chest. (It’s also a bit disconcerting when your hot flashes are fiercer than your wife’s.)"
"Hand in hand with the hot flashes came the food cravings. I lusted after Cheetos and Peanut Butter M&M’s, maple-walnut milkshakes, and spaghetti and meatballs buried in a blizzard of Parmesan. Isn’t it funny how cravings very rarely involve tofu, bean curd or omega-3 oils?
Then there was the weight issue. During the six months I was on Lupron I gained about 25 pounds. That was partly a byproduct of the cravings, but it also stemmed from the hormonal changes triggered in my body.
And I hated it, hated it, hated it. I had never had to worry about my weight, and I began to understand why media aimed at women and girls obsess over weight so much. It was strange and unsettling not to be able to tell my body, “No,” when it wanted to wolf down a fistful of Doritos slathered with scallion cream cheese.
When I wasn’t devouring a king-size Italian sub or smoldering from a hot flash, it seemed that I was crying. The tears would usually pour down when I got ambushed by some old tune: “Sweet Baby James” and “Fire and Rain” by James Taylor, “That’s the Way I’ve Always Heard It Should Be” by Carly Simon and, yes, “It’s My Party” by Lesley Gore. Not only was I temporarily menopausal, but it appeared that I was also turning into a teenage girl from the early 1970s.
There were other side effects, too, like headaches and fatigue. But when I started drinking Diet Coke for the first time in my life, my son Owen couldn’t take it anymore. He said, “Dad, are you turning into a chick?”
Even though Dana only got to spend a brief time on the outer precincts of menopause, it did confirm his lifelong sense that the world of women is hormonal and mysterious, and that we men don’t have the semblance of a clue!
Wednesday, June 3, 2009
The Caregivers journey
There is nothing harder or more complex in life than to tend to a loved one whose life is slowly and painfully draining away. The caregiver- be it the parent, spouse or sibling face difficult and in some cases incredibly painful choices. While more attention is focused on the patient, we sometimes forget that such illness not only attacks the patient but indeed the entire family. How does the caregiver, who may make this difficult and painful journey alone, cope with the physical, mental and psychological problems that lie ahead?
The journey often starts with a call that says your mom's fallen, your dad's had an accident or your spouse has a frightening diagnosis. Little do you realize the turns and twists that await you on this tortuous journey of caregiving – a role you never asked for nor sought but one that will dominate your life into the future. You realize, perhaps for the first time, you have a new role—family caregiver and the family rock.
The first reaction to the news is usually one of stunned disbelief—“It’s not possible” or “Why me?” But as the hard facts sink in, there is both denial and defiance. Both the patient and the caregiver often refuse to accept the verdict- often delivered by the doctor with clinical accuracy in guise of objectivity. Could the diagnosis be wrong? Is there another expert to be consulted? Thus starts a period of intense activity. There is a search for the best experts in the world, the latest advances in medicine, and experiences of others who have survived. “We will beat this thing” you tell your loved one. Experts and doctors are consulted, blood tests and other diagnostic instruments repeated, google searched for any other options around the world for any cures. It is the period too when family and friends express their concern and offer suggestions as who to consult and what to do, sending cuttings from newspapers about the latest advances in medicine. Each day brings hope of a new cure or a new discovery and promise of a different future.
Sadly, in most cases, this does not sustain and the cold hard realization sets in that there are no silver bullets and no quick cures to what afflicts your loved one. The sprint for recovery now becomes a marathon. You begin living with a new uncertainty. You know that you're not going back to the old normal. You, the caregiver, are slowly gradually left alone as family and friends, the crisis of discovery over, return to their respective lives. Thus begins a period where you realize that you must now learn to live with an affliction that would be long lasting. “When I first learned that my husband would be an invalid and had none or little chance of a full recovery, my first reaction was of relief. At least I would have him for some more time. And that perhaps over time medical breakthroughs might help his recovery” says one caregiver whose husband was diagnosed with terminal cancer.
It is true that things usually settle down after the first excitement is over but you are now entering the most painful part of the journey. First the daily routines take over. The patient is slowly learning to accept the limitations of the affliction. But burdened with the sole daily responsibility, the physical toll mounts on the caregiver and soon fatigue takes over. As the days stretch out and the constant drumbeat of doctors and medicines dominates daily life, you will often despair and yearn for the old days. Pangs of regret over travels not taken and visits not made will overwhelm you at times. Sometimes anger overcomes you as the prospect of endless ministrations lies before you without end. It is a cell that you cannot break out of and sometimes you lash out at your loved one till remorse overtakes you. He or she did not choose this illness and is as much a prisoner of this situation as you are. Yet watching life go by does require a resolution and steel as you tend to your loved one. Some come to terms with the limitations and yet continue to lead a busy and productive life. There can be high points too as you both discover new things despite constraints and continue building memories for the future. You soon realize that it will continue to be a rollercoaster—you may be up and down for weeks or even months. But surviving this despite the physical toll it is taking becomes crucial during this period since you are essentially now alone.
In the Indian system the caregiver used to have a support system. In the joint family system, the invalid remained a part of the family and everybody pitched in to help and care along of course with the servants. But with the breakdown of the joint family system, the nuclear family has become increasingly ill equipped to handle any major long term illness particularly since there are so few institutional facilities to help the caregivers. In the US there are a large number of nursing homes and assisted family care institutions, and even a home care service provider service, and finally a hospice, but besides being ruinously expensive, they rarely satisfy the urge to hew closely to the loved ones at their times of need
And then there is the psychological toll even as flashes of past joys intermingle with the sorrows to come in future. As a caregiver, you totally commit yourself to caring for another person who no longer functions as they once did in the normal scheme of life. You may give up our job, your own independence, and very often your lifestyle. You become so involved with the care of that person out of love that you become removed from normal day to day living. Your entire life revolves around comforting and making our loved one feel loved. In a very real sense you have given your life for another but this comes at a price. Gail Sheehy advises the caregivers “You've become very good at caregiving by now. You're the only one your loved one trusts. You believe you're the only one who truly understands what he or she needs. You're seen as heroic. You're playing God. But you know what? We ain't God. We can't control disease or aging. And if we keep trying we'll be overcome by stress and fatigue and come to a dead end. You were convinced you could do it differently. But a few years into it you break down in tears and total fatigue. You've given up so much. You absolutely must come up for air or you'll go down in despair.” This lesson is the hardest to accept.
Slowly as your loved one’s conditions worsens, there comes the acceptance that this long journey can have but one end. Yet there remains a fierce desire to prolong this journey even as the daily setbacks mount. Yet no one can answer your most burning question. How long? He too understands and begins to withdraw into silences as he comes to term with his mortality. Besides making sure that those left behind are well provided for, he will also wonder what life would be for them when he is no longer around. This is where the process of separation must begin. It is a slow and painful progression, but the other way is to lose your self and go down with the person you're caring for. That would be a double tragedy.
And then, suddenly, it's over. Your loved one has passed on. Now what? Maybe you've forgotten who you were before. You've been consumed for so long by caring for someone you love. You have given of yourself and done a beautiful thing. Unfortunately for the caregiver the journey does not end with the end. For you have now have to embark on a new journey to come back to a life without your loved one, a journey almost as difficult as the one just completed.
And when the grieving is over, it is time to begin the process of finding your way back into the world. How does one pick up the pieces and start to live again? It will come down to taking one step at a time, some will walk slower than others and some will speed their way back out into the world! Often there will be one step forward and two backwards. While it is not an easy process, remember that there is a life after caregiving! You just have to look forward and find opportunities that are once again there for you. Renew old friendships, find a job that you feel good doing, do volunteer work, find a new or renew an old hobby but you must begin to take a few small steps towards living again! One of the best therapies is finding a friend you can talk to, one who will listen and support you as you ease back into the world!
Soon you will find that life does still exist and you are a part of it! After the first months of mourning, grief will come out of nowhere when you least expect it. Don't sit around and wait for depression to set in. Pick up your passion—whatever you do where time passes and you don't even notice—and follow it. It will lead you on a new path. Look at it as a new adventure in your life and your tribute to the one who has gone before you.
The journey often starts with a call that says your mom's fallen, your dad's had an accident or your spouse has a frightening diagnosis. Little do you realize the turns and twists that await you on this tortuous journey of caregiving – a role you never asked for nor sought but one that will dominate your life into the future. You realize, perhaps for the first time, you have a new role—family caregiver and the family rock.
The first reaction to the news is usually one of stunned disbelief—“It’s not possible” or “Why me?” But as the hard facts sink in, there is both denial and defiance. Both the patient and the caregiver often refuse to accept the verdict- often delivered by the doctor with clinical accuracy in guise of objectivity. Could the diagnosis be wrong? Is there another expert to be consulted? Thus starts a period of intense activity. There is a search for the best experts in the world, the latest advances in medicine, and experiences of others who have survived. “We will beat this thing” you tell your loved one. Experts and doctors are consulted, blood tests and other diagnostic instruments repeated, google searched for any other options around the world for any cures. It is the period too when family and friends express their concern and offer suggestions as who to consult and what to do, sending cuttings from newspapers about the latest advances in medicine. Each day brings hope of a new cure or a new discovery and promise of a different future.
Sadly, in most cases, this does not sustain and the cold hard realization sets in that there are no silver bullets and no quick cures to what afflicts your loved one. The sprint for recovery now becomes a marathon. You begin living with a new uncertainty. You know that you're not going back to the old normal. You, the caregiver, are slowly gradually left alone as family and friends, the crisis of discovery over, return to their respective lives. Thus begins a period where you realize that you must now learn to live with an affliction that would be long lasting. “When I first learned that my husband would be an invalid and had none or little chance of a full recovery, my first reaction was of relief. At least I would have him for some more time. And that perhaps over time medical breakthroughs might help his recovery” says one caregiver whose husband was diagnosed with terminal cancer.
It is true that things usually settle down after the first excitement is over but you are now entering the most painful part of the journey. First the daily routines take over. The patient is slowly learning to accept the limitations of the affliction. But burdened with the sole daily responsibility, the physical toll mounts on the caregiver and soon fatigue takes over. As the days stretch out and the constant drumbeat of doctors and medicines dominates daily life, you will often despair and yearn for the old days. Pangs of regret over travels not taken and visits not made will overwhelm you at times. Sometimes anger overcomes you as the prospect of endless ministrations lies before you without end. It is a cell that you cannot break out of and sometimes you lash out at your loved one till remorse overtakes you. He or she did not choose this illness and is as much a prisoner of this situation as you are. Yet watching life go by does require a resolution and steel as you tend to your loved one. Some come to terms with the limitations and yet continue to lead a busy and productive life. There can be high points too as you both discover new things despite constraints and continue building memories for the future. You soon realize that it will continue to be a rollercoaster—you may be up and down for weeks or even months. But surviving this despite the physical toll it is taking becomes crucial during this period since you are essentially now alone.
In the Indian system the caregiver used to have a support system. In the joint family system, the invalid remained a part of the family and everybody pitched in to help and care along of course with the servants. But with the breakdown of the joint family system, the nuclear family has become increasingly ill equipped to handle any major long term illness particularly since there are so few institutional facilities to help the caregivers. In the US there are a large number of nursing homes and assisted family care institutions, and even a home care service provider service, and finally a hospice, but besides being ruinously expensive, they rarely satisfy the urge to hew closely to the loved ones at their times of need
And then there is the psychological toll even as flashes of past joys intermingle with the sorrows to come in future. As a caregiver, you totally commit yourself to caring for another person who no longer functions as they once did in the normal scheme of life. You may give up our job, your own independence, and very often your lifestyle. You become so involved with the care of that person out of love that you become removed from normal day to day living. Your entire life revolves around comforting and making our loved one feel loved. In a very real sense you have given your life for another but this comes at a price. Gail Sheehy advises the caregivers “You've become very good at caregiving by now. You're the only one your loved one trusts. You believe you're the only one who truly understands what he or she needs. You're seen as heroic. You're playing God. But you know what? We ain't God. We can't control disease or aging. And if we keep trying we'll be overcome by stress and fatigue and come to a dead end. You were convinced you could do it differently. But a few years into it you break down in tears and total fatigue. You've given up so much. You absolutely must come up for air or you'll go down in despair.” This lesson is the hardest to accept.
Slowly as your loved one’s conditions worsens, there comes the acceptance that this long journey can have but one end. Yet there remains a fierce desire to prolong this journey even as the daily setbacks mount. Yet no one can answer your most burning question. How long? He too understands and begins to withdraw into silences as he comes to term with his mortality. Besides making sure that those left behind are well provided for, he will also wonder what life would be for them when he is no longer around. This is where the process of separation must begin. It is a slow and painful progression, but the other way is to lose your self and go down with the person you're caring for. That would be a double tragedy.
And then, suddenly, it's over. Your loved one has passed on. Now what? Maybe you've forgotten who you were before. You've been consumed for so long by caring for someone you love. You have given of yourself and done a beautiful thing. Unfortunately for the caregiver the journey does not end with the end. For you have now have to embark on a new journey to come back to a life without your loved one, a journey almost as difficult as the one just completed.
And when the grieving is over, it is time to begin the process of finding your way back into the world. How does one pick up the pieces and start to live again? It will come down to taking one step at a time, some will walk slower than others and some will speed their way back out into the world! Often there will be one step forward and two backwards. While it is not an easy process, remember that there is a life after caregiving! You just have to look forward and find opportunities that are once again there for you. Renew old friendships, find a job that you feel good doing, do volunteer work, find a new or renew an old hobby but you must begin to take a few small steps towards living again! One of the best therapies is finding a friend you can talk to, one who will listen and support you as you ease back into the world!
Soon you will find that life does still exist and you are a part of it! After the first months of mourning, grief will come out of nowhere when you least expect it. Don't sit around and wait for depression to set in. Pick up your passion—whatever you do where time passes and you don't even notice—and follow it. It will lead you on a new path. Look at it as a new adventure in your life and your tribute to the one who has gone before you.
Monday, June 1, 2009
Emerging Technologies that will change the world
Each year Technology Review, a journal for the alumni of MIT, chooses 10 emerging areas of technology that will soon have a profound impact on the economy and on how we live and work. These advances span information technology, biotechnology and nanotechnology-the core of TR coverage in every issue. All of these areas merit special attention in the decade to come. In each area TR also highlights one innovator who exemplifies the potential and promise of the field. Since these predictions have been ongoing at least since 2001, it is worth examining how good has been the track record of the premium technology university in the world.
Brain-Machine Interface : Nicolelis predicts that Human brain machine interface will allow human brains to control artificial devices designed to restore lost sensory and motor functions. Paralysis sufferers, for example, might gain control over a motorized wheelchair or a prosthetic arm-perhaps even regain control over their own limbs
Flexible Transitors : Cherie Kagan, may have opened the door to cheap, flexible electronics that pack the mojo needed to bring ubiquitous computing closer. Her breakthrough? A compromise: transistors made from materials that combine the charge-shuttling power and speed of inorganics with the affordability and flexibility of organics.
Data Mining : also known as knowledge discovery in databases (KDD): the rapidly emerging technology that lies behind the personalized Web and much else besides. the future of data-mining technology? One very hot area is "text data mining": extracting unexpected relationships from huge collections of free-form text documents. Another hot area, says Fayyad, is "video mining": using a combination of speech recognition, image understanding and natural-language processing techniques to open up the world's vast video archives to efficient computer searching.
Digital Rights Management | Singh, president of ContentGuard, is on a mission to commercialize content protection in a wired world. Digital rights management, or DRM, is "the catalyst for a revolution in e-content," says Singh. "DRM will allow content owners to get much wider and deeper distribution than ever before,
Biometrics Visionics develops and markets pattern-recognition software called FaceIt. In contrast to the main competing technology, which relies on data from the entire face, FaceIt verifies a person's identity based on a set of four facial features that are unique to the individual and unaffected by the presence of facial hair or changes in expression. They plan to build the first line of "biometric network appliances-computers hooked to the Net with the capacity to store and search large databases of facial or other biometric information. The appliances, containing customers' identification data, can then receive queries from companies wanting to authenticate e-transactions. And while consumers will be able to access the system from a cell phone, PDA or desktop computer, Atick expects handheld devices to be the biggest market
Natural Language Processing a new generation of interfaces that will allow us to engage computers in extended conversation--an activity that requires a dauntingly complex integration of speech recognition, natural-language understanding, discourse analysis, world knowledge, reasoning ability and speech generation.
Microphotonics In Joannopoulos' lab, photonic crystals are providing the means to create optical circuits and other small, inexpensive, low-power devices that can carry, route and process data at the speed of light
Untangling Code Kiczales champions what he calls "aspect-oriented programming," a technique that will allow software writers to make the same kinds of shortcuts that those of us in other professions have been making for years.
Robot Design Pollak demonstrated how to fully automate the design and manufacture of robotics by deploying computers to conceive, test and even build the configurations of each robotic system: in short, to use robots to build robots.
Microfluidics Stephen Quake uses tiny volumes of fluids thousands of times smaller than a dewdrop. Microfluidics is a promising new branch of biotechnology. The idea is that once you master fluids at the microscale, you can automate key experiments for genomics and pharmaceutical development, perform instant diagnostic tests, even build implantable drug-delivery devices-all on mass-produced chips. It's a vision so compelling that many industry observers predict microfluidics will do for biotech what the transistor did for electronics.
And what does TR predict will be the emerging technologies in 2009:
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