The Tribune, Chandigarh, India

Strike at Maruti Suzuki
There are no winners in this stand-off

The The third strike this year by workers at Maruti Suzuki’s Manesar plant could not have come at a worse time. Recessionary trends, inflation, a hike in fuel prices and bank interest rates have already led to a decline in the sale of vehicles and the net profit of most of the automobile companies. Against this backdrop, it is intriguing that the country’s largest car-maker, Maruti Suzuki, which has already suffered losses of over Rs 630 crore because of the strike, is unable to reach an early compromise. Meanwhile, the industrial unrest has spread to not just other units of the company but also threatens to engulf other automobile companies . Haryana’s auto belt is estimated to employ half a million workers, and the brewing discontent among them bodes ill for an industry which has been buoyant not so far back.

What started off as a section of the workers’ desire to form a union of their own has degenerated into violence, go-slow and sabotage. The management has made no secret of its opposition to a new union and accused political parties of instigating the workers. The latter, on the other hand, complain of discrimination, bad labour practices and poor service conditions for workers on contract. The political parties have also upped the ante by alleging that the management backed out from a tripartite agreement and deployed armed bouncers to terrorise workers into submission.

Independent studies maintain that 50 per cent of the workers in the automobile sector are being hired on contract, paid less than permanent workers and fired at will. The workers also do seem to have a point when they say that though the companies have been reaping hefty profits , they are unwilling to share it with the workers. While there are laws to protect the interests of contractual workers, they are rarely implemented in the automobile sector, it would appear. The government and the labour department, rather than playing with fire, must mediate and settle matters without further delay. Or else, everyone will be a loser.

Dengue in Punjab
It must be nipped in the bud

Two very clichéd expressions taught at the very basic level of schooling seem to have escaped the attention of health administrators in Punjab. These are “prevention is better than cure” and “nip a problem in the bud”. More than 60 years after Independence the state is still found grappling with administrative inertia to come out of the grip of dengue. With just 0.29 per cent of the GDP allocated to health-care services in the state, the monsoon, floods and the subsequent epidemics still remain a nightmare for the common men and women. Year after year people are forced to deal with the traumatic experience of fighting malaria and dengue fever, a feature that has become an inevitable, unavoidable outcome of the monsoon.

That a simple procedure like fogging of the entire areas, where the growth of female aedes egypti mosquitoes is expected, particularly where standing water is found, is being ignored by the authorities. After 241 confirmed cases of dengue in Bathinda district alone, 25 from Talwandi Sabo, and about 10 from other districts, and with about 2,000 suspected cases admitted in Ludhiana, it is time the state health machinery geared up to avoid such calamities by adopting preventive measures. The Lahore dengue nightmare, with over 5000 confirmed cases in the city, should have rung the alarm bell for the health administration in Punjab when initial cases began to trickle in. But, perhaps, they don’t believe in nipping the problem in the bud!

The health administration callously awaits a crisis to erupt, rather than preventing a crisis. Besides, on the one hand, Punjab is boasting of creating some world class super-speciality hospitals in the state, on the other, common people are not provided with basic amenities of hygiene, essential for healthy environs. In the absence of any vaccine or, even a specific treatment for the virus of dengue, the health authorities must give the required emphasis to preventive measures to avoid an epidemic kind of a situation.

Thought for the Day

Your vision will become clear only when you can look into your own heart. Who looks outside, dreams; who looks inside, awakes. — Carl Jung

ARTICLE

ISI’s dangerous activities
It has a history of destabilising govts
by G. Parthasarathy

Indian “intellectuals” and bleeding heart liberals have zealously believed that “dialogue” alone can address the animosity of the Taliban and its ISI mentors towards India, as though these organizations are akin to Mother Teresa’s Sisters of Charity. The Taliban’s animosity towards India became manifest when 75 American cruise missiles targeted Taliban and Al-Qaida strongholds in Afghanistan on August 20, 1998. The Americans accidentally did India a favour. Instead of eliminating Osama bin Laden or Mullah Omar, the cruise missiles destroyed an ISI camp in Khost, training men of the Harkat-ul-Mujahideen for terrorism in Jammu and Kashmir. A few months later, the then ISI chief, Lt-Gen Ziauddin, met the Taliban “president” and asked him to provide 20,000-30,000 “volunteers” for “jihad” in Kashmir. The Taliban chief startled General Ziauddin by offering 500,000 volunteers for this effort!

Throughout the hijacking of IC-814 in December 1999, the Taliban was guided by ISI handlers, who took charge of the three terrorists released by India. One of them, Omar Sayeed Sheikh, proceeded to kill American journalist Daniel Pearl. Shortly thereafter, with the help of the then ISI chief, Lt-Gen Mahmud Ahmed (later sacked at the instance of the Americans), the Sheikh transferred $100,000 to Mohammed Atta, the leader of the 9/11 hijackers. Masood Azhar, another recipient of Indian generosity during the hijacking, soon met Osama bin Laden and Mullah Omar in Kandahar and organised the December 13, 2001, attack on Indian Parliament.

The third released terrorist, Mushtaq Zargar, now arranges cross LoC infiltration from Muzaffarabad. Post-9/11, the Taliban, its Haqqani network affiliates and the Lashkar-e-Taiba have targeted Indian workers and consulates across Afghanistan, culminating in the July 2008 attack on the Indian Embassy in Kabul and the subsequent attack on our embassy officials in October 2009. Illusions that the Taliban would be reasonable partners in a dialogue for national reconciliation in Afghanistan have been shattered by revelations of the Mullah Omar-led Quetta Shura’s involvement in the treacherous assassination of former Afghanistan President Burhanuddin Rabbani.

The ISI has a long-standing tradition of destabilising elected governments and meddling in elections within Pakistan. Former ISI chief Lt-Gen Asad Durrani revealed in Pakistan’s Supreme Court that during the 1990 elections the ISI had provided “logistics support” to a right wing alliance, the Islami Jamhoori Ittehad (IJI), and even obtained funds for the IJI from a Karachi businessman, Younus Hamid. Durrani subsequently revealed during investigations led by Interior Minister Maj-Gen Nasrullah Babar that on the instructions of then Army Chief, General Aslam Beg, a small proportion of funds collected for the 1990 elections was given to politicians like Ghulam Mustafa Khar (uncle of Hina Rabbani Khar), Hafeez Pirzada and Mairaj Khalid.

The bulk of the money collected from businessmen, according to General Durrani, was deposited in the “K Fund”” of the ISI to finance its external operations. Referring to this claim by General Durrani, General Babar noted in his own hand: “This is false. The amount was pocketed by (then Army Chief) Beg.”

Indulging in such activities was not a monopoly of General Durrani, who had subsequently approached Prime Minister Nawaz Sharif for approval of the ISI’s involvement in narcotics trading to finance its operations in Punjab and Kashmir. Nawaz later revealed that he had “refused such a plan”, adding: “As a citizen of Pakistan, I was shocked.” Durrani’s predecessor, Lt-Gen Hamid Gul, who fancied himself as a strategic genius, met his waterloo when he tried to dislodge President Najibullah’s forces from Jalalabad just after the Soviet withdrawal from Afghanistan. General Gul had no inhibitions in boasting about his affiliation with radical Islamic elements in Pakistan and Afghanistan.

Durrani’s successor, Lt-Gen Javed Nasir, a fundamentalist of the Tablighi Jamaat, earned an even more notorious reputation. When the ISI’s involvement in the 1993 Mumbai bomb blasts was established and Pakistan faced threats of further American sanctions, Nawaz Sharif was forced to sack Nasir, who has recently been indicted by the War Crimes Tribunal at The Hague and faces charges of having violated UN sanctions by providing weapons to Muslim elements during the Bosnian civil war.

The names of subsequent ISI chiefs constitute a veritable “Rogues Gallery’’ of the people involved in terrorism. General Ziauddin’s activities have already found mention. His successor Lt-Gen Mahmud, now like Nasir, a bearded activist of the Tablighi Jamaat, had to be sacked by General Musharraf at the behest of the Americans for his close ties with the Taliban and other radical Islamic groups. General Kayani’s tenure as ISI chief saw Osama bin Laden finding haven in Abbottabad. His successor Nadeem Taj, a Musharraf protégé, had the dubious distinction of also being eased out because of his hard line Islamist propensities. It was during Taj’s tenure that the ISI’s links with the 2008 attack on the Indian Embassy in Kabul was established.

His successor and the present ISI chief, Lt-Gen Shuja Pasha, commenced his tenure with the 26/11 terrorist strike by the Lashkar-e-Toiba on Mumbai. Lt-General Pasha has been summoned to appear by a US court in a case filed by the families of the victims of 26/11 after the revelations of Dawood Gilani, aka James Headley, about ISI involvement. He is also reported to have met the indicted Lashkar military commander Zakiur Rehman Lakhvi in jail.

Pakistan’s military, whose current protégé is Imran Khan, has forced the weak Zardari government to launch a tirade against the Americans after an all-party meeting convened by Prime Minister Gilani, a long-time Army favourite. At this meeting, former Prime Minister Nawaz Sharif pointedly remarked to the military leaders present that there must be a “reason” why the whole world was holding Pakistan responsible for terrorism. Pakhtun leader Mahmood Achakzai remarked: “There will be peace in Afghanistan within a month provided the ISI stops exporting terrorism to that country.” The Awami National Party and the Barelvi Sunni Tehriq have voiced similar sentiments.

It is astonishing that an army that has brought disrepute to the country, never won a war and succeeded in losing half of Pakistan in 1971 still claims to be the “’guardian of Pakistan’s territorial and ideological frontiers”. Given its continuing adventurism in relations with India and Afghanistan and its bluff and bluster in dealings with the US and its allies, the Pakistan Army now seems leading the country further down the road of extremism, violence and economic stagnation. Pakistan’s military is also set to go wrong yet again if it continues to believe that China will back it to the hilt if it proceeds on a collision course with the Americans.

MIDDLE

Apple of My Eye
by Shelley Walia

I heard about Steve Jobs's death while I was listening to the songs of the sixties' singer, Joan Baez. Her songs are poignant and I was further saddened by the thought that Steve and she had once dated.

Steve is gone, but his passionate commitment to innovation has left a profound mark on me. I find it difficult to distinguish between him and his products, between the dance and the dancer. And as I also belonged, like him, to the counter-culture of the sixties, I have some indefinable affinity to his approach to life. I feel I have known him deeply owing to my long and happy association with the Apple Macintosh.

I first heard of Steve when we reached Cambridge in the mid-eighties. The university had opened an Apple Macintosh store where computers were available at a discount. I remember my wife and I buying our first Apple Classic, commonly know as the Macintosh, at a whopping cost of £800. My wife, who was doing her doctoral research at Cambridge, used it to type her thesis. It was the first real personal computer possessing the fanatical care, elegance and 'the aloof sheen of Steve's personality'. It had a 40mb memory which we then upgraded to 80.

Though out of our reach, this was the only computer which already had the facility of a mouse and windows that were later hijacked by Microsoft. I look at the Apple Mac today and realise the enthusiasm and the creativity behind the sleepless nights Steve must have spent on each meticulous detail, even on the font, the colour of the cord or the cardboard packing in which we carried it to our flat.

Within a few years came the SE and the LC Apple Macintoshes but we doggedly remained faithful to our Classic. And then, one day, there appeared the Apple Powerbook, a laptop! I remember our excitement the day we paid over £1800 for it. We brought it back to India where it was the envy of everyone who saw it. In those days, very few people in India possessed laptops. So rare were the Apple machines especially, that once when our printer cartridge ran dry, we were driven to Nehru Place in Delhi where too it was unavailable.

But by the mid-nineties, the Apple Laser Printer became available and we managed to bring one home. It cost us £1500. Luckily, being scholars, we didn't have to pay any duty on it which was then 300 per cent --a formidable charge few could afford.

Many years have gone by and we have graduated to other Apple products like the Ipod, the Iphone and the Ipad. Just the other day, because of being in disuse for many years, the Powerbook went dead. The Classic still stares at us longingly from one corner. Steve's spirit still lives on in the age-old Apple machines that we remain loyal to even though they are no longer in use, having been replaced by faster machines. They are the reminders of the story of inspiration of a visionary who never went to any business school, was neither a software nor a hardware engineer, but one who always thought differently. His courage to follow his heart and his intuition is a lesson for each one of us who have a history that we share with him.

OPED — HEALTH

Living with rheumatoid arthritis
In India, there is poor awareness about the disease and treatment options available. Not only that, there is also dearth of trained rheumatologists
Dr Shefali Khanna Sharma

Thinkstock photos/Gettyimages Over seven million people in India suffer from rheumatoid arthritis (RA) and yet its diagnosis and treatment rates are low. With a prevalence of 0.5 per cent to 0.75 per cent, RA is a serious autoimmune disease that has debilitating and devastating impact on the quality of a patient's life, often causing extreme fatigue, severe pain that worsens over time and irreversible physical deformities. Inadequate awareness among the patients, caregivers and even general practitioners and orthopaedicians results in prolonged symptomatic treatment, increasing incidence of morbidity and mortality.

What is rheumatoid arthritis?

Rheumatoid arthritis is an inflammatory disease, a form of chronic arthritis mainly affecting joints and tendons. An inflamed joint looks swollen and red, and appears warm to the touch. The disease usually starts in the wrists, hands or feet, and can spread to other joints and other parts of the body, if untreated it can lead to deformities that affect the quality of life. Not only this, it could also lead to premature atherosclerosis and heart attacks and affect other organs like lungs, abdominal organ and kidneys. RA is one of the most common chronic inflammatory arthritis that causes disability.

A positive outlook on the part of the patient as well as the doctor helps in coping with the difficulties in the treatment of RA. In India, there is poor awareness about the disease and treatment options available along with a dearth of trained rheumatologists. Preliminary treatment is most often symptomatic relief for joint pain and swelling, reducing chances of appropriate treatment for arresting the disease and slowing down its progression by a rheumatologist, this approach needs to change. Early detection and right medicines now make the dream of a pain-free life possible for patients with RA.

RA has Female: Male ratio of 3:1 and most of the females in India do not get proper diagnosis and treatment. People of any age can develop it, but it is most common between the ages of 30 and 50 years, and among women. Usually, inflammation is the body's way of healing, in rheumatoid arthritis; however, the immune system starts to attack the body instead of defending it. The immune system contains a complex organisation of cells and antibodies designed normally to "seek and destroy" invaders of the body, particularly infections. Patients with autoimmune diseases have antibodies in their blood that target their own body tissues, where they can be associated with inflammation.

Systemic illness

Because it can affect multiple other organs of the body, rheumatoid arthritis is referred to as a systemic illness and is sometimes called rheumatoid disease. The inflammation affects:

Thin synovial membrane lining the joint capsule

Tendon sheaths (tubes in which the tendons move)

Bursae (sacs of fluid that allow the muscles and tendons to move smoothly over each other)

There is also a systemic inflammation throughout the body producing excessive fatigue and stiffness in the morning. Studies have shown there are certain genes that make one susceptible to the disease. RA however dos not run in the family according to experts.

It is true that the exact cause of the disease is not known but many symptoms are due to excess antibodies produced by cells populating the synovium which are involved in the immune function of the body. These cytokinins facilitate the release of powerful enzymes that destroy the synovial lining and bone of the joints.

Diagnosis

The diagnosis of patients with established RA is generally difficult as it is based upon symmetrical polyarthritis characteristically involving small joints of the hands with/without deformities, subcutaneous nodules, radiological changes (cartilage loss, juxtrarticular osteopenia, erosions) and the presence of rheumatoid factor. The diagnosis is predominantly clinical and is supported by imaging and laboratory investigations.

Typical onset of the disease is anywhere between age 20 and 45. RA can affect any joint throughout the body but is most often seen in joints in the hands (wrist joints and the finger joints closest to the hands). It can also affect other parts of the body. Any joint damage done by the disease is permanent, therefore early detection and drug treatment is essential to minimize or even prevent any permanent joint damage. RA can be a little difficult to diagnose as it begins with only subtle symptoms such as achy joints or a little stiffness in the morning. There is no single confirmatory test which diagnoses early RA with 100 per cent certainty. Instead the diagnosis is based on a variety of factors as mentioned above.

Not all symptoms are present in people with early RA and these problems may be present in some people with other rheumatic conditions as well. RA independently increases the mortality and other complications. RA is considered as malignant disease with poor prognosis and increased mortality. Life expectancy is reduced by 3-10 years in RA depending on age of onset and severity of symptoms.

RA is associated with serious co-morbid conditions like infections, cardiovascular complications, respiratory disorders etc. Rate for work disability in RA is almost 40 per cent after 10 years of disease onset. Today, doctors believe there's an early window of opportunity as little as 3 -4 months to treat rheumatoid arthritis before the onset of irreparable joint damage. Studies show that taking action quickly may even put the disease into remission.

Treatment

Education and counseling: Successful management of patients with RA depends upon empowering the patients with the knowledge about the chronic and fluctuating course of the disease, side effects and costs of the drugs and the rigorous and continuous need of physiotherapy. The communication depends upon the patient's educational and social background and may require several sessions. More the time spent in counseling, more the chances that patient comes to terms with the chronic nature of the disease and adheres to treatment.

Patients are likely to follow up with the same doctor/hospital if they have been counseled well. Patient's anxiety regarding various diets, climatic conditions and other personal habits should be addressed. Smokers should discontinue smoking as it adversely affects the course of the disease and alcohol intake should be restricted in view of the hepatotoxicity of drugs used in RA.

The positive aspect of therapy has to be spelt out that patients with drug therapy can hope to live a better quality of life. The goals of treatment are to relieve pain and swelling of the joints so that cartilage and bone loss are minimised with improvement in functional quality of life. In terms of disease activity, the aim would be monitoring for side effects of drugs. This is to be done by judicious use of DMARDs (Disease Modifying Anti-Rheumatic Drugs).

Therapy is to be individualized in each patient to ensure sustained tight control of inflammation for better long-term outcome. At a given time, depending upon the disease burden, a particular patient will have features of both disease activity and damage (the later accruing with progress of time). Drug therapy will help to resolve activity while rehabilitation including surgery is required to restore functionality.

Multidisciplinary approach

Drug therapy is advised by the internists/rheumatologists, physiotherapy and rehabilitation by trained physiatrists and surgical care by the orthopedic surgeons when necessary.

Pharmacotherapy of RA consists of the following:

Anti-inflammatory drugs: Non-steroidal anti-inflammatory Drugs (NSAIDs) reduce both pain and inflammation. These include ibuprofen, diclofenac and nimesulide.
Steroids are the most potent anti-inflammatory drugs. They should be used judiciously by a physician as they have long term side effects.
Conventional disease modifying anti rheumatoid drugs (DMARDs): Methotrexate is the 'anchor' drug that should be used first in patients at risk of developing persistent disease. Others include sulfasalazine, leflunomide and hydroxychloroquin.
Biologicals: DMARDs are anti-TNF, Tocilizumab, Abatacept, and Rituximab. The newer category of drugs is agents which block the key mediators of inflammatory response. These drugs have dramatically improved the outcome of the disease and will contribute to the future improvements in the management of RA, thus preventing long term disabilities with the disease. At the present time, these drugs are expensive and can be afforded by a minority of patients.

Symptoms

Morning stiffness that lasts at least an hour and is experienced for at least six weeks.
Swelling in three or more joints for at least six weeks.
Swelling of the wrist, hand, or finger joints for at least six weeks.
Swelling of the same joints on both sides of the body.
Changes in hand X - rays that are characteristic of rheumatoid arthritis.
Rheumatoid nodules on the skin.
Blood positive for rheumatoid factor and/or anti- citrullinated peptide/protein antibodies.

The writer is Rheumatologist, Dept of Internal medicine, PGIMER Chandigarh, and Ex-Associate Professor in Dept. of Medicine at All-India Institute of Medical Sciences, New Delhi