Life-style versus body systems
Dr S.K. Jindal
A drug is defined as a substance used as or in a medicine. Essentially, drugs are used for the treatment of diseases and disorders. Man has used medicine in one form or the other since time immemorial. Whether it is the natural ingredient of a plant, the aroma of a sacred fire or a synthetic chemical substance prepared in the laboratory, all have been used to modify the metabolic systems of the body for its functional benefit.

Allergy and asthma: a quick, hard look
Dr Shakuntala Lavasa
MORE than 10% of the population in the country is estimated to be suffering from one or the other allergy ailment. Allergy in the airways is called allergic rhinitis and asthma. The number of asthma patients has increased by about 50% over the past 30 years in the developing countries.

Schizophrenic patients: unmet needs 
Dr Rajeev Gupta
SCHIZOPHRENIA, a psychotic mental disorder, continues to baffle mental health professionals throughout the world. In spite of the best treatment available, nearly one third of the schizophrenic patients become chronic and continue to have problems of management, productivity, social roles and rehabilitation. 

HEALTH BULLETIN
Master your anger
ANGER can be a good thing. It rouses us to act. It was the common man's anger at injustice and wrongdoing which led to many social reforms. But anger becomes a bad thing when we lose our temper at the wrong things, at a wrong time or in a wrong manner.

Q&A
Population initiatives
The activist as an artist: An interview with Shabana Azmi
FOR some time, the different roles she plays seem to have been merging. The parliamentarian who legislates on matters of national importance, the actress who acts out the well-rehearsed roles that win her accolades, and the UNFPA Goodwill Ambassador who advocates women's rights, all find a culmination in Shabana Azmi.

Life-style versus body systems
Dr S.K. Jindal

A drug is defined as a substance used as or in a medicine. Essentially, drugs are used for the treatment of diseases and disorders. Man has used medicine in one form or the other since time immemorial. Whether it is the natural ingredient of a plant, the aroma of a sacred fire or a synthetic chemical substance prepared in the laboratory, all have been used to modify the metabolic systems of the body for its functional benefit. A drug, therefore, has served as a chemical or, more precisely, a biophysiochemical weapon against different illnesses.

With the passage of time and an increased understanding of pathophysiological systems, the role of drugs has widely expanded. They are now being increasingly employed to tune the human mind and the body for a desired life-style. The medical advice to change the life-style is perhaps, difficult to follow. Rather than changing the life-style, people opt to change the body systems to suit a particular life-style. The pharmaceutical industry has obviously responded positively to the strong market forces.

The use or abuse of habituating and addicting drugs for an ailing or a stressed mind is nothing new. It has always been there in one form or the other. From different intoxicating beverages to the kicking puffs and snuffs, the euphoric substances have been used as mental crutches. As times have passed, people have shifted from "Soma Rasa" to scotch and from "bhang" to brown sugar. In spite of their general effects, these drugs are generally not considered in the more recent category of life-style drugs. These do affect behaviour and mental function and, therefore, life-style. But, they are habit-forming as well as mentally and physically devastating.

Now we have drugs to maintain and sometimes modify our "normal" or, more specifically, adopted habits and practices. One can possibly go on with the usual eating, drinking, smoking, resting, lazying or flirting, and yet avoid or treat the consequences of the traditional vices. There are also drugs which are, or are likely to be available, on the counter in the general food stores. Needless to say that they are likely to be extensively exploited by advertising.

The two most important pieces of advice for good health concern the regulation of diet and physical activity. Obesity, and the consequences thereof, including joint pains and cardiorespiratory problems, result. Drugs to treat obesity without restrictions on food and prescriptions of exercise would be welcome by most people. Such drugs are already there in the market. The newer inhibitors of neurotransmitters such as sibitramine is quiet close to a safe and effective drug. In the near future, we may soon find television advertisements of a capsule of such a drug to be taken with every meal to get rid of the anxiety of gaining weight. Cholesterol-lowering drugs add further spice and may further liberalise the dietary intake.

Smokers have always found it annoying to visit medical practitioners to listen to the advice to quit. Many western countries, especially the USA, now list bupropion as a quit-smoking aid on the top of the sale list. The nicotine replacement therapy for smoking in the form of chewing gums and skin patches was always fraught with the risk of abuse. Bupropion is, perhaps, the first anti-nicotine agent used for this purpose.

Hormone replacement for menopause, contraceptive and abortion pills are some other examples of drugs used to live more happily and enjoy a more satisfying life. Somehow, medical aphrodisiacs have not yet penetrated the market and people often rely on heavy metals or extracts from different parts of animals including lizards, snakes, rhinos or tigers. The routine availability of such drugs is likely to storm the market in a manner similar to that of the anti-potency drugs — Viagra and the desi-Viagras!

Lastly, it is anti-ageing treatment which will win over most others. The age-perfect lotions, oils and creams are there for a healthy skin. Health tonics, vitamins and minerals already form a part of the daily menu of innumerable families. Vitamin E is one of the frequently used agent for good health. Even oxygen is used as a tonic and oxygen-bars are there in many cities in competition with health and fitness clubs. But the role of most of these agents is still unproven.

Undoubtedly, we are heading towards an era of greater reliance on substances and medicines to remain fit, and healthy, live long and maintain a personalised life-style. Nothing, however, is foolproof and no such writing should be considered as conclusive or authentic medical advice. It only indicates the trend of recent developments. We have a long way to go before we discard the traditional methods of achieving health and remaining healthy.

Dr Jindal is Professor and Head of the Department of Pulmonary Medicine at the PGI, Chandigarh.

Allergy and asthma: a quick, hard look
Dr Shakuntala Lavasa

MORE than 10% of the population in the country is estimated to be suffering from one or the other allergy ailment. Allergy in the airways is called allergic rhinitis and asthma. The number of asthma patients has increased by about 50% over the past 30 years in the developing countries. Asthma is still underdiagnosed and undertreated. It is common to see patients perpetually on antibiotics and on frequent nebulisation in doctors' clinics for years together without specific anti-inflammatory (preventive) treatment and without allergen identification even in "difficult asthmatics".

Among several factors contributing to asthma, allergy is most important. An allergen induces inflammation in the airways and the results are sneezing, nasal congestion, coughing, breathlessness and sputum production. Itching watery eyes, skin rashes, urticaria and abdominal symptoms are also associate manifestations of allergy. Almost all asthma is allergic.

Seasonal asthma is usually caused by outdoor allergens like tree pollens, grass pollens, fungal spores etc. The pollen from trees growing in cities is more allergenic. DEP(diesel exhaust particles) act as carriers that transport allergens into the airway. Allergic sensitisation also correlates with automobile exhaust and distances of residences to roads with heavy traffic.

In Japan people living near busy roads lined with cedar trees have higher pollinosis than those living on similar streets with less traffic. We identified a new allergen — the "wheat threshing dust allergen" as a cause of asthma and rhinitis in April-May, which is a crucial period for examination-taking children and farmers.

Exposure to indoor allergens (dust, mite, cockroaches, cats and dogs and fungal spores) lies at the root of perennial asthma. People are spending 23 to 24 hours daily indoors. Homes are providing fabric reservoirs for allergens. About 82% children have television sets in their rooms. They have at least one damp wall, cockroaches, dust and mites in their homes. They spend split lives between four environments — home, school, daycare and after-school tuitions. A combination of indoor living with little activity clearly contributes to perennial asthma. The added burden is also modern food with additives, artificial flavours, colours and preservatives. The list is exhaustive. Allergens play an important role in 75% to 80% of the patients. It is undoubtedly correct that anti-inflammatory therapy is the cornerstone of asthma-care but equally important is allergen detection and management to prevent inflammation. Allergen-specific avoidance advice and education are now the first line of treatment for extrinsic asthma, atopic rhinitis and atopic dermatitis.

For reliable allergen detection, allergy tests by a specialist in allergy are necessary. Allergy tests do not consist of merely skin pricks as is being done today by people with no knowledge but much vested interest, misdiagnosing allergies and putting patient to inconvenience, and science into disrepute. An allergist is a physician who has a sound knowledge of the variability of allergens based upon the geographical region, seasons, occupation and hobbies of individual, is trained in allergen selection, preparation of relevant test material if the commercial kits do not represent what you want, test techniques, confirmation of tests by other challenge methods like provocation tests and specific lgE (allergen detection by a blood sample), and techniques of aerobiological surveys.

Aerobiological surveys are done to see the relevance of allergens in the patient indoor, workplace and breathing zone environment so that the necessary modification can be advised. An allergy test is relevant only if the patient is seen as an individual. Performing a battery of tests is of little consequence.

Allergens are most important triggers and allergy testing is the preferred method of identifying allergens. To keep focusing on possible suspects, particularly in food, by hit and run trials such misguided avoidance of food, may be quite disastrous for growing children. Experts warn against overprotection and hysteria.

Dietary management of children must always be approached with a keen awareness of nutritional needs of the growing child. When the diagnosis suggests that allergens are important, the mainstay of the therapy is environmental control.

There is evidence that the avoidance of allergens, specially of some foods, animal exposure and dust mite may prevent children from atopy to develop asthma. When allergen avoidance is not practical, specific immunotherapy becomes the answer. Allergen-specific immunotherapy is no longer a controversial treatment. Recently, the WHO and other international and national bodies have concluded and confirmed that immunotherapy significantly reduces asthma symptoms and asthma medication requirement and hyper-reactivity of airways. It means that not only allergens but also non-specific triggers stop bothering you. These are important findings. They can lead to improved asthma control. Immunotherapy decreases medication requirement. Inhaled steroids is the main therapy is asthma. Any reduction in this type of treatment, while maintaining good asthma control, is welcome. The success of immunotherapy depends upon the precise allergen identification. Equally important are other issues like who is the ideal recipient, monocomponent therapy with purified allergens, an optimal schedule with timely modifications, etc. Only a trained and experienced allergist should select allergens, initiate immunotherapy and supervise it. Properly conducted immunotherapy by a trained allergist after an accurate allergy diagnosis based upon in vivo and in vitro tests and proper aerobiological correlations is safe and beneficial.

The expert panel recommends a deep inquiry about exposure to allergens in every asthma patient and allergy-testing (in vivo or in vitro) at least for those with persistent asthma, irrespective of the level of severity to direct avoidance or immunotherapy.

Asthma has emerged as one of the world's major serious and increasing global health problem predominantly attacking the young. Let us attack asthma with all scientific approaches.

Dr Shakuntala Lavasa is an allergy specialist and a paediatrician of repute. (Contact numbers 562239, 563447 or 782766).

Schizophrenic patients: unmet needs 
Dr Rajeev Gupta

SCHIZOPHRENIA, a psychotic mental disorder, continues to baffle mental health professionals throughout the world. In spite of the best treatment available, nearly one third of the schizophrenic patients become chronic and continue to have problems of management, productivity, social roles and rehabilitation. The common symptoms of the disease are: odd behaviour, inappropriate emotions, hearing of voices, ideas of reference, suspiciousness, aggressiveness, physical violence and a lack of normal emotional feelings.

This article has been written with the purpose of highlighting some of these problems in order to help The Tribune's readers — and the general public — to have a better understanding of the disease-process.

Marrying a chronic schizophrenic: The question of marrying or not marrying a chronic schizophrenic is often raised with the treating psychiatrist. The parents of the patients are always under various kinds of pressure to marry off their schizophrenic children. The problem is equally pressing — for the male and the female patient. One question which the parents often ask is: "Doctor ! For how long can we take care of our unmarried children? After all, one day we will not be alive and your patients will become supportless and come on the road." Their fears and apprehensions are genuine. In our country, there are very limited institutions which can manage such patients for a prolonged period.

In my opinion, if a chronic patient is well maintained on drugs and does not show active symptoms like hallucinations, (hearing voices) and delusions (false and fixed beliefs) for at least the past two years or more, has reasonably recovered to look after himself and is clearly aware of the physical and emotional needs of the future spouse and the family, one can think of getting him or her married. One should never think of marrying off those patients who are in the active stage of the disease and are having symptoms like physical violence, delusious, hallucinations gross behavioural abnormalities, suspiciousness etc.

It is a wrongly held belief that marriage improves mental patients. Under this belief many parents marry off their children and the families frequently face complications later. It is important to remember that no one can give an assurance to the effect that a particular patient, who is at present not having any active symptoms and is well maintained on drugs, will not have a relapse.

Problems like marital disharmony, separation and divorce are common among chronic schizophrenic patients. Paranoid patients, showing a very high degree of suspiciousness against their spouses make the life of their partners a living hell. They keep on making accusations about the character of their partners. I always advise the parents of such patients to inform "the other party" about the clinical and other problems being faced by the patients. But my clinical experience shows that hardly any parent discloses the truth.

The common problems faced by the married schizophrenics are sexual dysfunctions like impotency, pre-mature ejaculation and loss of libido, and these may be partially caused by the anti-schizophrenic drugs.

  Motivation to work becomes the first casualty. Schizophrenics lose the requisite zeal and enthusiasm for work. Their output starts falling later, and they become unproductive. Both under-employment and unemployment are common among such patients.

The schizophrenic illness goes on for a long period. It blunts intellectual skills. It affects abstract thinking too, thus putting many limitations on the higher cognitive functions.

Dr Rajeev Gupta, a versatile psychiatrist and medical writer based in Ludhiana, has inherited the common-man-oriented professional ethics of the legendary Professor, Dr N.N. Wig.

HEALTH BULLETIN
Master your anger

ANGER can be a good thing. It rouses us to act. It was the common man's anger at injustice and wrongdoing which led to many social reforms. But anger becomes a bad thing when we lose our temper at the wrong things, at a wrong time or in a wrong manner.

Uncontrolled anger usually hurts other people, and it always hurts ourselves: It hurts us because it wastes energy, affects our judgement, increases tension and leaves us fatigued. Anger can cause ulcers, headaches and a host of other ills.

Anger can be a deadly enemy: People realise the truth of all this but find it difficult to master their rage and control their temper.

What to do when you are angry?
Take up some hard physical labour: Take up some hard physical labour so that you are using the extra energy, which has been created. To go out into the garden and start digging or to go for a long and strenuous walk will calm away the anger.

Take it out on something inanimate: Take it out on something inanimate rather than taking it out on people. Go out and throw stones at something. Use a punch-ball. The idea of this is to work off your anger on something where it does no harm.

Keep your voice down: Force yourself to keep your noise down. When a person is angry he usually raises his voice and shouts. If you make a deliberate attempt to speak quietly and slowly, you find your anger becoming much more controlled.

When angry, look at your face in the mirror. You look funny! If possible, go and look at your face in the mirror. The idea behind this suggestion is that an angry person usually looks very funny to someone who is watching. If you look at your angry face, you will realise how ridiculous it is to get angry.

Understand the reason for your anger: Ask yourself quickly — Why do I get angry and lose my temper? There are one or two usual reasons. Maybe, there is a sense of insecurity somewhere which is making us oversensitive. Here, we need to examine our minds and try to find out why we feel insecure. Another reason is frustration. We are frustrated from doing something we want to do. The first necessity to overcome is to realise that you have problems with anger. Avoid, as far as possible, the situations which lead to frustration.

Learn to accept what can't be altered. Endure it with a smile. A great thing in life is to learn to accept the things we cannot alter. Do your best and leave the rest that is out of your control. Getting angry will not help. It will only make things more difficult. If you are angry because some other person in the office or school is frustrating you, remember again that a man who loses his temper has lost his case. Accept the fact that you cannot persuade someone else to accept your point of view. There is no reason why they should. Getting angry and losing your temper will accomplish nothing.

Is it worth getting angry?: Cultivate a sense of perspective. The things we so often lose our tempers about are trivial compared with the great issues of life. Is it worth getting excited and losing our temper over something which will appear quite small later on?

It is something you have to cultivate. Make up your mind and find out what really matters to you in life and get accustomed to seeing things against that background. If friendship matters to you, it is not worth the risk of losing a friend by losing your temper.

Try to understand people: Make a habit of trying to understand people. Understand people especially those who tend to make you angry. Ask yourself,"Why do I always get angry with him/her?" Try to enter into their experience what does it feel like to be them? Try to state quite clearly to yourself. Why you find them so irritating.

Learn to forgive: There is nothing which helps to control one's temper so much as an understanding of people. Unless you know something of the background of a person and something of his outlook on life, you are not really qualified to judge him. So go for understanding.

Relax: Practise a relaxed attitude to life. Anger is the opposite of relaxation. A relaxed person cannot lose his temper. By being relaxed, you will accomplish far more.

Pray: If you have a religious faith, use it. You can pray your way out of a bad temper. Relax in the presence of God and fix your mind on His serenity.

— Dr Savita Malhotra, MD, PhD; Dr Adarsha Kohli, MA, Ph.D; and Shruti Shourie, MA.

Q&A
Population initiatives
The activist as an artist: An interview with Shabana Azmi

FOR some time, the different roles she plays seem to have been merging. The parliamentarian who legislates on matters of national importance, the actress who acts out the well-rehearsed roles that win her accolades, and the UNFPA Goodwill Ambassador who advocates women's rights, all find a culmination in Shabana Azmi. Shabana, who recently added yet another National Award to her already sizeable collection for her portrayal of a politician in Godmother, was in New Delhi recently to attend the session of Parliament. The following are the excerpts from an interview Population Times had with her:

Q Even as an actress you are being seen more and more by people as a social activist who has adopted the medium of cinema in pursuance of a social agenda. Your role in Godmother is the most recent example.

A Yes, I have been playing strong roles — there are several films I can recall in which I played the character of a woman who responds strongly to a challenge.

Q You have been associated with women's issues not just as an activist but also as a legislator. How far has women's health figured on the national and state agendas?

A Health is on nobody's agenda in India, and women's health even less. After 50 years of Independence, more women die from pregnancy-related complications in a week in India than the whole of Europe in one year.

Q What do you feel about the National Population Policy which has laid out a detailed plan that places women's overall health and well-being at the centre?

A The new Population Policy reflects the role that women activists have played in raising consciousness about safe motherhood. Now we need to change the mindset of those people who are going to implement this legislation.

Q What are your main concerns on the future of population programmes in the country?

A The National Population Policy is doing away with disincentives at the national level. But this is not happening at the state level. For example, in Madhya Pradesh the state government has declared that anyone with more than two children will be barred from taking government employment after January this year. They should realise that disincentives have not worked anywhere in the world, and India is no exception.

Q You are looking for consistency in the national and state population policies.

A Yes. But there is another interesting aspect to it. In many states, there are specific laws (disincentives) that have existed for years. Many of these states do not have state-specific population policies as yet, but have these laws nevertheless. In Uttar Pradesh, for instance, a woman who marries below the legal age at marriage for women (18) loses her claim to a government job. Now, whom does this law affect? Only women. And among the women, it affects the weakest of them - those who have no control over their lives and can be married off as and when their parents and others please. If there had to be a legislation, it should have been against those who force the girl into marriage rather than the girl herself! I can point out many instances of such laws in various states because of which women suffer.

Q What should be the focus of the health delivery system?

A In addition to meeting the shortfalls in infrastructure, equipment and medicine there should be a reorientation of health workers to their changed role as per the new population policy. I recently spoke to some ANMs in Mijwain, a small village in Azamgarh where my father has set up a welfare society. They told me that while earlier they were supposed to meet family planning targets, now the new population policy is stressing on health delivery. But where is the much-required training of the personnel?

Q How do you plan advocating women's reproductive health and empowerment?

A I will pursue my agenda at all the levels I work at — through the media, in Parliament and so on. Women's health has to become an emotive issue which has to translate into a top priority in developmental programmes in the country.