Walk for a healthy heart
Dr H.S. Rissam
THE heart is the most important organ in the body but heart attacks hang like the Sword of Democles over everybody's head. The sword can hit anybody, anytime, anywhere and at any age. In this dark scenario, however, there is a bright silver lining — a simple action like walking can prevent life threatening heart attacks!

Psychotherapy in India: a perspective — I
Dr Ajit Avasthi
THE present methods of psychiatric treatment for the neurotic, psychosomatic and various other psychiatric disorders include psychotherapeutic techniques of one form or the other as well as behaviour modifications, environmental manipulations, drug treatment with psychotropic agents and ECT etc.

HEALTH BULLETIN
No hazard in homoeopathy
I had always defined homoeopathy as a mild, hit-and-trial method, something close to quackery. Some "sweet tablets" laced with alcohol, if suited, could cure, but finally one had to turn towards allopathy if symptoms persisted.

Q&A
Dr Gurinderjit Singh, a senior consultant dermatologist, answers reader’s questions

Walk for a healthy heart
Dr H.S. Rissam

THE heart is the most important organ in the body but heart attacks hang like the Sword of Democles over everybody's head. The sword can hit anybody, anytime, anywhere and at any age. In this dark scenario, however, there is a bright silver lining — a simple action like walking can prevent life threatening heart attacks!

The rapidly rising menace of heart disease has become such a major public health problem that the World Health Organisation (WHO) has decided to observe World Heart Day on 24 of the September every year. The Theme of World Heart Day for the year 2000 was: "Walk for a Healthy Heart".

The new epidemic: At the threshold of the new millennium Coronary Artery Disease (CAD) is looming large as the new epidemic afflicting Indians at a relatively younger age with severe and diffuse forms of lesions. CAD in Indians has become a challenge for many research centres world-wide. The prevalence of CAD has progressively increased in this country during the past few decades, particularly among the urban population. In addition to conventional risk factors — high blood pressure (hypertension) diabetes mellitus (DM), high blood cholesterol (hypercholesterolemia) and tobacco smoking, — there are new risk factors like high triglycerides, low levels of good cholesterol (HDL-Cholesterol), lipoprotein - a (Lp-a), high LDL-cholesterol, rising affluence and rapid modernisation associated with a sedentary, stressful life-style which seem to be playing a very serious role in the rising incidence.

The emerging scenario: The risk of CAD in Indians is three to four times higher than in the White Americans and six times higher than in the Chinese and 20-times higher than in Japanese. Indians become prone as a community to CAD at a much younger age. Premature CAD is defined as heart attacks occurring below the age of 40 years. Indians also show a higher incidence of hospitalisation, morbidity and mortality than other ethnic groups. This global phenomenon of prematurity and severity suggests that the disease starts at an early age and has a malignant and progressive course. According to one coronary angiography observation, Indians living in Malaysia have a 15 times higher rate of CAD than Chinese and a 10 times higher rate than the local Malays below the age of 40.

In my own observation in West Asia, out of the patients admitted in CCU with acute MI below the age of 40-years, 80 per cent were Indian-expatriates as compared to 20 per cent of native Arabs, whereas demographically Indian expatriates were only about 10 per cent of the local population.

Lazy life-style and lack of exercise: Out of all known risk factors the worst and self inflicted one is the sedentary life-style (the life-style of comfort, luxury, laziness, very little physical activity and no regular physical exercise). In earlier times, our elders were much more physically active. Men walked from home to the place of work or they used bicycles to go to their offices and shops or business centres.

Women personally attended to most of the day-to-day responsibilities, including house-hold chores. Rural women folk would walk to the fields where their husbands were tilling the land. Urban women would go walking for shopping or social visits. The present scene is completely different. Men and women use vehicles even for short distances — whether to go to the place of work or move otherwise. Leisure and recreational activities have changed from morning walks to late-night dinners and from sports to television-watching.

All this has resulted in a lack of physical exercise, an increase in weight, a high incidence of diabetes, high blood pressure and high levels of cholesterol. These factors, in combination, cause a severe damage to the heart producing angina or myocardial infarction. Most people are not exercising not because they do not have time or they are busy; they do so because they are Lazy — Just Lazy!

Why walk and exercise: It is mandatory that people should take out special exclusive time of at least 40-60 minutes everyday for physical exercise of any type — for walking, jogging, swimming or sports.

Exercise is known to improve all the cardiac risk factors (i.e hypertension, diabetes and excessive weight) as it does exactly the opposite of what a sedentary life-style does to the body. Exercise also increases or raises the good cholesterol (HDL) in the body. Walking, like jogging, cycling, swimming and dancing, is an aerobic exercise. During exercise the heart rate increases in direct proportion to oxygen consumption by the body tissues. It is interesting to note that people who regularly exercise have lower resting heart rates (a lower pulse rate). Therefore, they are able to perform their day-to-day activities at a much lower heart rate than the sedentary people. Their cardiac reserve is higher and better. Therefore, when they do some exercise or indulge in physical activity, they can do it for a longer time without straining their hearts.

Bonus: Other than exercising the heart and developing physical stamina, walking gives you a feeling of well-being that affects everything around you. The feeling of well-being is produced because exercise releases "endorphins" in the blood stream. Endorphins are the "morphine"-like substances produced naturally by the body. It is a sedative, a pain-killer and a relaxant. Walking gives you a shot of healthy and natural morphine-which produces a "feel good effect" every time you walk. It makes you feel nice, and creates a positive state of mind. It helps you to think better and to like things around you, including the people around you.

Caution: Walking as an exercise is the best prescription against an impending heart attack. There is, however, a word of caution for those who develop chest pain or any other symptoms on walking. They must seek advice from a physician before they continue their exercise programme. Caution is also required during unfriendly weather conditions like severe heat, humidity and cold.

Practical tips: Walking is the most economical, convenient and safe exercise. For walking you do not need any equipment, any companion or a special team, a turf or court. There is no reservation or advance booking to be made for the slots or the partners. You just need plain canvas shoes and the WILL to walk. Walk at least four to six km a day or 30 km a week or 100 km per month or 1000 km in a year. Everyday, make an entry in your calendar of the number of kilometres you have walked. If you are short of the required distance for the week, you should complete the shortfall in the next week. The same is true for the month. Complete the month's quota. If there is a shortfall, it must be completed by the next month. So the year's total is at least 1000 km. Celebrate the New Year, your birthday, anniversaries or any other special day by walking 1 km extra. Reward yourself with extra kilometres of walking. Persuade your spouse, friends, neighbours and well-wishers to walk with you. In 40 years of your active walking, you shall be able to walk around 40,000 km which is interestingly the same distance required to travel around the planet earth! Walk for a healthy heart; for a long life. A healthy long life!

Dr Rissam, MD, DM, is a senior consultant cardiologist at Escorts Heart Institute and Research Centre, New Delhi.

Psychotherapy in India: a perspective — I
Dr Ajit Avasthi

THE present methods of psychiatric treatment for the neurotic, psychosomatic and various other psychiatric disorders include psychotherapeutic techniques of one form or the other as well as behaviour modifications, environmental manipulations, drug treatment with psychotropic agents and ECT etc. Regardless of the most skilled application of psychopharmacology and other physical methods of treatments, much human misery still remains and perhaps cannot be handled by any means other than some sort of psychotherapy.

Reservations are often voiced by Indian psychiatrists and various other mental health professionals about whether psychotherapy as practised in the abundant West in applicable or possible in countries or communities which are developing rapidly but still have deeply ingrained traditions, socio-cultural beliefs and practices, are economically poor but spiritually rich and have lower psychological sophistication. The general notion is that people of developing countries are somehow happier than materially prosperous westerners who are afflicted with emotions and mental tensions that arise more from the greater degree of complexity with which their society has developed. Conversely, mental illness is just about equal in developing and developed countries.

"Psychotherapy is the treatment, by psychological means, of problems of an emotional nature in which a trained person deliberately establishes a professional relationship with the patient the object (1) of removing, modifying or retarding the existing symptoms, (2) of 'mediating' disturbed patterns of behaviour and (3) of promoting positive personality growth and development". This is perhaps the most widely accepted definition of psychotherapy given by Wolberg in 1967. Do all people define psychotherapy in the same way or are there important differences? This question is highly relevant to the practice of psychotherapy in India.

Romano had given a very simple and realistic definition: psychotherapy is the utilisation of the psychological measures in the treatment of sick people. Kolb defined psychotherapy as the treatment of emotional and personality problems and disorders by psychological means. Frank defined psychotherapy as a form of help in which a trained, socially sanctioned healer tries to relieve a sufferer's distress by facilitating certain changes in his feelings, attitudes and behaviour through the performance of some activities with him.

It is quite apparent from the definitions mentioned here that there is a wide agreement on the point that by psychotherapy are meant those therapeutic manoeuvres which can be called psychological, as opposed to physical, in the treatment of problems of an emotional or psychological nature. The differences in the definitions of psychotherapy are primarily in two areas: (1) the nature and qualifications of the therapist, and (ii) the degree in which the relationship must be deliberate and structured to qualify as psychotherapy.

Witkower and Warnes noted in 1974 two important similarities between psychotherapies practised all over the world. (1) There is an intense emotional, confiding relationship between the therapist and the patient. (2) The therapist and the patient come to share an identical view.

The history of psychotherapy in India: The essence of psychotherapy had been present in all traditional societies all along, particularly if psychotherapy is definable as the unmediated interpersonal method of mitigating suffering. In India, it has existed in a submerged form, interwoven with social structures and social mores; in religious practices, customs,myths and rituals.

The schools mysticism, yoga and the way of Nirvana propounded by Buddhism had much in common in comprehensively promoting health. In Indian parlance, health is considered as a real positive concept. All the tradition aims at the transformation or spiritual restructuring of the individual through a variety of meditational approaches and through the guidance of a guru who supports the "adhikari" (deserving disciple).

With the European suzerainty spreading over the Indian subcontinent, especially British rule, western medicine came to be introduced in this country.

However, the Ayurvedic and Unani systems still existed and continued to be popular in large sections of the Indian population. During the British period, there was little psychiatry practised outside mental hospitals, two exceptions being Kolkata and Mumbai (Calcutta and Bombay then).

Girindrashekhar Bose, the founder of the Indian Psychoanalytic Society, can be considered to have brought modern psychotherapy in India in 1921. Bose submitted his thesis on the concept of repression for which the University of Calcutta awarded him the degree of Doctor of Science. Unaware until then of Freud's work on this concept, Bose presented his original views about repression which significantly differed from those of Freud. While Freud laid stress on the social and biological factors causing repression Bose emphasised that one wish might be modified or repressed only by another subjective wish working in opposite relationship with the former. Bose's theory of infantile wishes was a clear theoretical innovation. Bose also stimulated and encouraged others in psychoanalysis. The Indian Psychoanalytic Society got affiliated to the International Psychoanalytic Association in 1922.

The influence of the British school of psychoanalysis in India was seen when Lt Col Owen Berkley Hill, then Superintendent of the European Mental Hospital of Ranchi, began practising psychotherapy. By and large, Kolkata remained an active psychoanalytic centre. Dr Emilio Servadio, an Italian psychoanalyst practised psychotherapy in Bombay from 1938 to 1945 until he returned to Rome. Servadio trained a few analysts by providing personal apprenticeship. Dr K. Massani, a Parsi psychiatrist was one of them. He too migrated to the U.K in 1967.

Awakening of cultural sensitivity: The first significant note of discontent with the practice of western psychotherapy in India was expressed by Surya and Jayarama at the 16th annual conference of the Indian Psychiatric Society in 1964. They said that the "present day-Indian psychiatrist" was still a product of western training. Over a length of the time he had learnt his medical and psychiatric lessons in a language and in conceptual frameworks which were totally foreign to the milieu of his birth and habitation. Words by their very nature were loaded with powerful motivational and conative aspects. The Indian patients simply did not react to the words and concepts thrown at him even if they understood English. They lamented that one should deeply ponder over the implications of what would have been the study of psychiatric thought in this country if English was not the language of our transactions. If serious attention was not paid to this aspect, psychotherapeutic theory and practice would fail and our patients would be reduced to a set of prestige-loaded jargon.

Surya and Jayarama argued that people around the world are not alike and those of one culture differ from those of other cultures in many important ways which may have direct relevance to psychotherapy, such as religious or philosophical background, the experiential repertoire, language, modes of affective expression, moral and social norms and more, so the culturally determined conflicts and defences.

Various important reasons because of which the applicability of the western-type psychotherapy in India is questioned were elaborated by Prof Vijoy Varma in 1982.

Dependence: It is said that an average Indian is more dependent on other people as compared to an average westerner. It can be questioned as to how far western psychotherapy, with its high emphasis on autonomy, can be presented for such people.

Psychological sophistication, verbal abilities and introspection: Psychological sophistication, at least to the extent of considering possible psychological reasons for illness, and ability for introspection are considered essential for psychotherapy. Indian patients lack these attributes. The orientation of Indians rather than being psychological is more likely to be either physical or metaphysical, or mystical.

Confidentiality and dyadic relationship: Professor Varma noted that confidentiality in psychotherapy was not so important to the Indian patient and that he might not mind discussing his illness with a psychiatrist in front of friends and family members who might actually be perceived as therapeutic allies.

This raises questions regarding the relevance of confidentiality and strictly one-to-one relationship that are the hallmarks of western individual psychotherapy.

Patient expectations: An average Indian patient may expect too much from therapy — a kind of magical expectation! They may expect immediate and total cure as if by a miracle.

Personal responsibility and decision making: The Indian patient expects more to be told by the therapist and is often hesitant to exercise his own choice. In the western type of psychotherapy, the therapist and the patient come together as adults, responsible for his own behaviour and capable of making his own decisions. In Indian patients, a therapist has to assume a more directive attitude — suggesting, sympathising, manipulating the environment etc.

Guilt vs shame: Indian patients demonstrate a significant amount of shame. Shame is said to be directly related to immediate social disapproval. Western patients exhibit a lot of guilt and the psychotherapy model is oriented towards dealing with feelings of guilt.

Guilt is said to be dependent on identification and on values which have become deeply internalised and assimilated.

Religious and social beliefs: The question is raised whether the Hindu concept of rebirth and reincarnation can have important implications with regard to psychotherapy. The belief that one life does not terminate at its death, but that one is born again and again in some form is deeply ingrained in the core value system. The concept of fatalism is closely related to Hindu philosophy.

The social distance between the patient and the therapist: The Indian patient identifies the therapist with a superior class and assumes a submissive position in relation to the therapist. Western-model psychotherapy requires that the patient and the therapist should meet at an equal level and jointly find solutions to the problems.

To be concluded

(In part II of his article , Dr Awasthi, an eminent teacher-clinician from the PGI, describes the remarkable development of psychiatry in India).

HEALTH BULLETIN
No hazard in homoeopathy

In the case of a chronic disease, investigations revolving around the physical constitution of the patient, his mode of living and habit, his age, his social interaction, his moral and intellecteral characters are important features to be taken into consideration.

An alternative system

For the treatment of communicable diseases appearing in an epidemic form, homoeopathy has a special method of treatment. Take, for example, hepatitis. All symptoms of an epidemic disease cannot be found in any one person, but certain symptoms will be found in a few. All the similar symptoms are put together and a medicine is selected. This medicine becomes curative as well as preventive for that epidemic.

Hope leads to cure

— Anita Kashyap

A Alopecia (hair loss) can be scarring or non-scarring Both can be divided into two types: when the hair is lost evenly and patterned, and when certain areas of the scalp show bald spots.

A Several situations such as fever, pregnancy, emotional stress and excessive dieting induce a large number of hair to go prematurely into the resting (telogen) phase. Since the phase lasts for three months, hair loss starts only after that. But in due course, new hair takes the place of the lost hair.

A People who are bald have hair follicles that are genetically programmed to minaturise under the influence of post-pubertal androgens. Probably, several genes inherited from both mother and father influence the severity of baldness.

A About one-third of balding patients, who use the topical minoxidil solution, experience significant hair regrowth. Oral finasteride may be somewhat more effective and can be used in combination with topical minoxidil.

A Men — and occasionally women — can achieve permanent cosmetic improvement by undergoing a hair transplantation procedure. Hair follicles from the occipital area (donor site) are moved to the balding area (recipient site).

A Although many forms of alopecia can result in a circular bald patch, the most common causes are tinea capitis and alopecia areata. Tinea capitis is a superficial fungal infection with a predilection for children. Alopecia areata also affects children but adults develop the condition more often. The affected area may be totally hairless, but the scalp surface looks otherwise normal.

A In contrast to the telogen effluvium described earlier, cancer patients suffer from diffuse hair loss because of anagen effluvium. Patients receiving radiation therapy to the scalp, or getting systemic chemotherapy, can shed all or most of their hair. This is because of the direct effect on the hair follicle whose rapidly dividing cells are very susceptible to injury. This hair loss is reversible. (Moha Dai Oswal Cancer Hospital, Ludhiana).

A Today ayurvedic concepts are being interpreted in terms of the latest offshoots of science like molecular biology and neurophysiology. Interestingly, these concepts are being appreciated by modern scientists. Thus one cannot regard ayurveda as a mere cultural faith. I shall explain my views fully next week.

A Yes. Basant Kusumakar Ras is a comprehensive formulation comprising precious bhasmas of swarna, rajat, mukta, praval, etc, processed in the decoction of vasa, sandalwood, lotus flower, malta flower and sugandhabala. This drug rejuvenates and also fights diabetes.

For further information one can write to B-9, Hauz Khas, New Delhi-110016. (Ph. 91 11 6527631-32).