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Glory and shame Doctoring eligibility |
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Energising South Asia
What PM can announce on I-Day
Dealing effectively with ovarian tumours
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Glory and shame On
the one hand more and more woman players are doing the country proud by adding to the medal tally in international sports events, on the other a growing number of allegations of bias and sexual harassment against coaches and selectors mar the glory. There is the infamous case of the Sports Authority of India ( SAI) suspending Satvir Singh, wrestling chief coach at SAI Training Centre, Hisar, for his alleged sexual harassment of a teenaged wrestler. There is another scandal involving Ranjitha, a member of the Indian women's hockey team, who complained against chief coach M K Kaushik, which resulted in his suspension. Now the accusations made by a Commonwealth Games participant, Meena Kumari, against her coach of sexual advances echo a familiar tale. The coach, a senior official of the Indian Weightlifting Federation, has denied the charges though. Senior women players have often complained of facing sexually coloured comments and favours being done in the process of selection to those who oblige. Such cases support parents’ scepticism about letting their daughters follow their passion in sports. When the allegation of Sydney Olympic bronze medallist Karnam Malleswari against Sports Authority of India weightlifting coach Ramesh Malhotra of sexually harassing junior lifters was made public, the Union Sports Ministry changed the coaches to salvage its image. The sports fraternity, which should have come out in the open, maintained a stony silence. And women continue to be treated as second-class citizens of the sports world. These scams have opened the nation's eyes to the discriminatory attitudes that are so accepted that they may not even be recognised as exploitation. The age-old prejudices Indian sportswomen face -- from the coaches and the seniors -- continue. The previous government wanted to bring in legislation on national sports policy that would prevent sexual harassment of sportswomen and make sports bodies and their administration transparent in the country. The present government will, hopefully, bring about structural changes in the sports administration and selection processes to ensure that women, who bring glory to the country, do not have to compromise on dignity.
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Doctoring eligibility In
principle, the rules of a game are agreed upon before it begins, and not changed midway. Change can happen with the consent of all parties before a subsequent match. In the MBBS admissions in Punjab, the medical colleges, backed by the state government, are seeking to alter eligibility criteria to accommodate certain categories of students at the cost of others. The Medical Council of India has been requested by the state to lower the qualifying marks required by candidates under NRI and SC quotas as a large number of seats meant for these categories have remained unfilled. One, this is against the existing rules, which clearly state that any seats remaining vacant shall be transferred to the general category, a class of candidates that is forever short of seats available. Two, this amounts to giving double benefit to the reserved categories — a limited competition for the reserved seats, and a further lowering of even the minimum qualifying marks (50 per cent for
NRIs). The general students score way above the minimum required score and yet go without admission. But reserved and general category students are not the only parties in this feud. There is a third silent party — the general public, or patients to be precise, who are going to be subjected to treatment one day when these candidates graduate from medical colleges. Medicine is a critical service on which people’s lives depend. To have reservation is fine, but to lower the minimal standards is not. The debate also brings up some fundamental questions. NRI seats - meant to fetch hefty fees for colleges - though legal, are a borderline case on ethics. And if the qualifying marks are also lowered, it will amount to a virtual sale of seats, ignoring merit. As for lowering the requirement for SC candidates, it will harm the case of those who get admissions as per the existing rules. There is a bias against doctors from the various reserved categories. With undeserving people coming in, that will get worse.
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Thought for the Day
Let no one who loves be unhappy, even love unreturned has its rainbow. —James M. Barrie
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A REMARKABLE feature of the present European war is the dramatic suddenness with which hostilities were declared and the perfect state of preparedness for war in which all the Powers found themselves for this eventuality. In the meantime Germany, Russia, France and United Kingdom were all anxious to maintain peace. Germany and Austria were always preparing for war and augmenting their forces. One of the remarkable facts in the Austrian preparations is the scheme for introducing compulsory military service for women "elsewhere than in the battlefield". India's response to the call of duty
LORD Crewe's reply to the patriotic address presented by Indian residents in England once more shows how in times of danger differences of peaceful times totally disappear as they ought to. His Lordship gracefully acknowledges that he has been deeply impressed by the sentiments of "sincere and unselfish devotion to the common cause of the Empire which was so eloquently impressed in the address." India's unselfishness is manifest no less than her sincerity in the numerous demonstrations and enthusiastic offers of help from every province. The Government of India and Local Governments have been as deeply impressed as the Secretary of State with these gratifying manifestations of loyalty. The reply of His Excellency the Governor of Madras to the Advocate General on the subject of forming a legal Volunteer Corps shows that Government are sympathetically considering the proposal. There is also a further assurance that loyal offers of personal service from retired soldiers and members of the medical profession will be remembered "in case of need."
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Energising South Asia Apart from the announcement of additional economic assistance of $1 billion, Mr Modi’s visit resulted in a movement forward on border demarcation and a review of the contentious India-Nepal Treaty. But what can change the dynamics of India-Nepal relations and accelerate economic progress in Nepal is the mutually beneficial utilisation of Nepal's potential for 83,000 MW hydro-electric power. Despite this, Nepal imports electricity from India. An understanding was reached during the visit of Mrs. Sushma Swaraj to expedite the construction of transmission lines so that Nepal could import additional power from India. The World Bank is also assisting Nepal in enhancing trans-border transmission capacities by 1,000 MW. The expected signing of a power trading agreement during Mr. Modi's visit did not materialise because of Nepalese objections to what was quite evidently not a well-worded Indian draft. The agreement is, however, expected to be finalised shortly. Optimism has also been voiced about finalising an agreement for commencing work on the 5,600 MW Pancheshwar multipurpose project within the next year. One encouraging development is Nepal will issue 28 survey licences to Indian private companies for hydropower projects amounting to 8249 MW. Some of these surveys have been completed, but much work needs to be done for finalising power-purchase agreements and financial closure. The issue of the duration of these projects also needs to be mutually agreed upon. But progress appears to have been made in finalising details in the 900 MW Upper Karnali Project being undertaken by GMR. A word of caution is necessary. Energy diplomacy with Nepal will have to be conducted sensitively with patience and forbearance, given the country's current constitutional impasse. Energy cooperation seems to be increasing significantly with India's eastern neighbours who are members of the BIMSTEC. The experience of India's cooperation with Bhutan has been radically different from what has emerged in its relations with Nepal. Bilateral cooperation was initiated with the commissioning of a 60 MW hydro-electric project in April 2006. The first of six hydro-electric projects of 170 MW, the Tala Project, was commissioned in July 2006. Ten hydro-electric projects were agreed for implementation in 2009. Three of these projects are under construction. Project reports for four other projects have been finalised and are under examination by the two governments. The project reports for the other three projects are expected to be finalised soon. India and Bhutan appear well set to achieve the target of 10,000 MW by 2020. India commenced the supply of 250 MW of power to Bangladesh last year after the government-run Bangladesh Power Development Board and a subsidiary of India's National Thermal Power Corporation (NTPC) signed a deal on Feb 28, 2012. This followed an agreement signed during Bangladesh Prime Minister Sheikh Hasina's visit to New Delhi in January 2010. That agreement led to the establishment of a 500 MW cross-border interconnection between Baharampur in West Bengal and Bheramara in Bangladesh. The Chief Minister of Tripura recently confirmed the readiness of the state to supply a further 100 MW to Bangladesh, which provided unprecedented transit facilities for the movement of heavy equipment for the development of power plants in Tripura. India and Bangladesh are reported to have tentatively agreed to connect their distribution networks for the transfer of 6,000 MW of hydro-electric power from Assam to Bihar, via Bangladesh. The network could ultimately connect two other SAARC members — Nepal and Bhutan — opening up hydro-electric power generation across the region. There is huge hydropower potential in India’s Northeast. Arunachal Pradesh alone has the potential to produce 50,000 MW. Neighbouring Myanmar, with a hydro-electric potential of 40,000 MW, is ready to cooperate with both China and India in projects that meet its environmental concerns. The NTPC and the Ceylon Electricity Board (CEB) signed an agreement for setting up a 500 MW coal fired power plant, to be commissioned in 2016, in Sri Lanka's northern province. The two countries are also studying options for a high voltage DC Grid, linking either Madura or Tuticorin in Tamil Nadu to Anuradhapura or Puttalam. Though an agreement was reached on the “TAPI Pipeline” to bring gas from Turkmenistan to India through Afghanistan and Pakistan, it is unlikely that the security of this pipeline can be guaranteed for years. China has, in the meantime, commenced negotiations for a Turkmenistan-Afghanistan-China gas pipeline, which traverses through relatively violence and terrorism-free areas. Faced with pressure from the Saudis and Americans, the Nawaz Sharif government recently reneged on an agreement signed by President Zardari for an Iran-Pakistan pipeline. Iran, which incurred a substantial expenditure on this project, has threatened punitive legal action. The Nawaz Sharif government has also backed off from proposals for energy cooperation with India, under pressure from the army, repeating what it did in 1999. India should examine the prospects of obtaining Iranian natural gas directly through an undersea pipeline, estimated to cost $ 4-5 billion, to carry 31 million cubic metres of gas a day. But actual work can commence only after current international banking sanctions on Iran are eased, or ended. In these circumstances, we should realise that BIMSTEC is the regional grouping that offers the best opportunity for energy cooperation. We would find China filling the vacuum in yet another strategic sector, if we do not move imaginatively in developing energy cooperation across our land and maritime borders, as China is doing across Asia.
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What PM can announce on I-Day Ministry of Himalayan Affairs: The Himalayas have always been the ecological backbone for this subcontinent, and are vital for our economic security, environmental security and water security. The Department of Climate Change and the Indian Meteorological
Department should also come under this ministry. Implementation Commission: The Planning Commission has done very little. It is a major reason for the failure of the UPA. We do have good plans but their implementation is poor. So instead of a Planning Commission what we need is an Implementation Commission. Ministry for Centre-State Relations: There are many areas that are handled by various ministries with regard to the States. But there is no nodal coordinating agency. This Ministry for Centre-State Relations could be under a Cabinet Minister who would ensure a fair distribution of taxes, the roll out of the GST, the settlement of disputes between states such as on river waters. The Ministry for Geo Resources: By Geo, one understands what is in the earth. All this is discovered and exploited through the same exploration techniques. The Geo Ministry could consist of the Ministry of Petroleum and Natural Gas, Ministry of Earth Sciences, Ministry of Coal and Ministry of Mines. Ministry of Research and Development: The Ministry of Science and Technology must be enhanced to include Research and Development. R & D is an area where India is woefully lacking despite spending huge sums of money both on defence and other areas. This lack of self-reliance then brings in lack of self-esteem in the armed forces and in the nation. Ministry of Marine Resources: We have one of the largest coastlines and a separate Ministry of Marine Resources can help coordinate all aspects pertaining to it. For instance, the coastal sea floor under Indian control, as per the International Law of the Sea, is so large that we are in danger of neglecting various possibilities.
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Dealing effectively with ovarian tumours Ovaries
are the small, ovoid structures on either side of the uterus. Whenever we talk about cancers in women, we must be aware of masses or tumours — benign and malignant, of the ovaries. Although cancers of the ovary are the fifth most common cancer in women after breast, colorectal, lung and uterus; they are the most common cause of death in women due to cancer. Women with ovarian cancer have the least five-year survival rate as compared to all other cancers. This is because cancer of the ovaries is a "silent killer" — 70 per cent of ovarian cancer is diagnosed in advanced stages, which means that the disease is already widely spread in the abdomen by the time it is diagnosed.
Treatment at that late stage cannot cure but can simply help at improving the Quality of Life (QoL) parameters. The scenario is so alarming that any mass or tumour in the ovaries brings on fear and a panicky tendency to operate on all such patients. The patients themselves are frightened about any ovarian enlargement or mass. This may lead to excessive and unnecessary surgery in patients with benign disease and less than recommended surgery in those with ovarian cancer. With better knowledge about ovarian tumours available in the recent past, algorithms and protocols have been set in place which help decrease errors in management. It is important to understand and know your ovaries so that you can participate in the decision-making process with your gynaecologist. Predisposing factors Every year 220,000 women develop epithelial ovarian cancer (the most common type of ovarian cancer) worldwide. However, it is important to know these facts — the lifetime risk of developing ovarian cancer is 1 in 60; 90 per cent of ovarian cancers occur in women more than 45 years; the highest chance of getting ovarian cancer is after the age of menopause; the highest risk, among women in menopause, is between 60-64 years. With this data, it is clear that in a young, premenopausal woman, it's less likely that the tumour or mass detected in her ovary is cancer. In fact, in premenopausal women, almost all ovarian masses are benign. High-risk factors One must consider factors which indicate high risk for ovarian cancer as well as those favourable factors in women which make risk of ovarian cancer low. An important factor is age. Younger women, less than 40 years, are less likely to get cancer of the ovaries and if they do, survival rates are better than older women: 93 per cent vs 31 per cent at 1 year and 84 per cent vs 14 per cent at five years. Epidemiological studies have shown that the risk of ovarian cancer is reduced by states in which ovulation or release of egg does not occur. This means that pregnancy and the use of oral contraception pills are protective, and prevent development of ovarian cancer. Ovarian cancer is also known to be decreased in women who have had sterilisation procedures because of absence of menstrual products regurgitating backwards on the ovary. Processes in which egg formation is stimulated in larger-than-normal-numbers, as in IVF (Test Tube Baby), have been implicated, though not proven, for increased risk of ovarian cancer. Endometriosis and the common hormonal syndrome, PCOS, have also been linked with ovarian cancer. Hereditary factors Many ovarian cancers are hereditary and three main hereditary types have been identified — ovarian cancer alone; ovarian and breast cancer; and ovarian and colon (large intestine) cancer. The most important risk factor for ovarian cancer is the family history of ovarian cancer in a first-degree relative (mother, daughter, sister). The highest risk is if two or more first-degree relatives have ovarian cancer. The risk is less if one first-degree relative and one second- degree relative (grandmother or aunt) has ovarian cancer. All women simply must know whether there is history of cancer in the female members of her family — breast, ovarian or colon and even history of cancers in male members of her family — male breast, colon, prostate. A family history of cancer, especially certain cancers, puts a woman at higher risk for ovarian cancer which then requires higher alertness. In the younger, pre-menopausal age group, most ovarian masses are cysts. A cyst is defined as a fluid-filled structure less than 30 mm. The incidence of symptomatic ovarian cysts being malignant is one in 1,000 in premenopausal women and the risk of malignancy increases to three in 1000 women after menopause. Estimating which cyst is benign or malignant can be problematic without doing surgery, however most “simple” cysts are benign. A Simple Cyst is one which, on ultrasound, is lesser than 50 mm in diameter; has thin, smooth walls; no internal structures; and clear fluid inside the cyst. Such cysts in women who do not have any symptoms are “functional”, physiological and usually resolve and disappear without any medical or surgical intervention by the doctor within two to three months. After menopause Simple Ovarian Cysts are common even in older women after menopause, though lesser frequent than in younger premenopausal women. In the older age group one is frightened of any growth anywhere. Before the easy availability of expert ultrasound, all ovarian cysts in the post-menopause age group were considered as an indication for surgery; not anymore because of low risk of malignancy, less than one per cent of many of these cysts even in this age group. Such older, post-menopausal patients with no symptoms and simple cysts less than 5 cm and normal blood level of tumour markers like CA125 can also be simply watched conservatively without resorting to surgery. So the treatment of women with no symptoms and simple cysts less than 5 cm (with normal CA125 in older women) is to simply watch by repeated ultrasound (plus CA125 in older women) and wait for them to go away without panicking into surgical treatment. Complex
cysts Any cyst that does not fit into the strict definitions and criteria of Simple Cyst is called a Complex Cyst. Most cysts, including Complex Cysts, in young women are benign. Even when identified as benign, complex ovarian masses may require surgery. Ultrasound by the trans-vaginal route, not abdominal route, is the most effective way of evaluating an ovarian tumour. It can be used to identify certain features suggestive of benignity or malignancy. This “Pattern Recognition” by ultrasound is very sensitive and specific in complex cysts although no single ultrasound finding can definitely say whether a cyst is benign or malignant. As is true for all cancers, women diagnosed with advanced stage (Stage 3 or 4) have poor survival rates. On the other hand, women diagnosed with early stage (Stage 1) can be cured. The aim is to screen and diagnose ovarian cancer to pick up as early stage as possible. Ovarian cancer is termed as a “silent killer” but it is increasingly recognised that the majority of women with ovarian cancer experience some symptoms more frequently, more severely and more persistently than women who do not have the disease. Alert symptoms Bleeding after menopause is a very important complaint which is not normal and must be investigated. There is a complete algorithm devoted to the investigation and workup of postmenopausal bleeding and ovarian cancer investigation is part of it. The Guideline Development Group has therefore not included this, although it should be investigated, in the following alert symptoms for ovarian cancer: persistent abdominal distention (bloating); feeling full (early satiety); pelvic or abdominal pain; increased urinary frequency, urgency or a woman of 50 years age or more with symptoms diagnosed as Irritable Bowel Syndrome. These symptoms present within last 12 months and persisting or frequent more than 12 times in one month, especially if woman is 50 years of age or more, are significant to investigate for ovarian cancer. Other than this, one should be alert to symptoms not specific to ovarian cancer like unexplained weight loss, changes in bowel habits and fatigue. Unlike earlier times when all postmenopausal women were subjected to routine ultrasound of pelvis and CA 125 as ovarian cancer screening programme, it's now not considered necessary anymore. This is because there is no convincing evidence that ultrasound and CA125 screening of all women can detect early-stage, curable ovarian cancer in sufficient numbers, without an excessive number of non-malignant masses precipitating unnecessary surgery. Ovarian cancer also does not have a pre-invasive stage, like cervical cancer, which can be picked up by such screening programs. Investigating women with these symptoms leads to early pick up of ovarian cancer. Therefore, most important is to remain alert to symptoms which have been found to have higher presence in women with ovarian cancer. Open surgery The best outcome in women with diagnosed ovarian cancer is in doing an open surgery, removal of both tubes and ovaries, lymph nodes removal, several biopsies and a full “staging” procedure carried out by a trained gynae-oncologist at a cancer centre. However, many older, post-menopausal women have benign ovarian cysts. Therefore such a protocol is neither advisable nor feasible for all patients with ovarian tumours. No currently available tests for ovarian cancer offer 100 per cent sensitivity or specificity of diagnosis. Ultrasound is unable to differentiate between benign and malignant with 100 per cent accuracy. CA125, the blood test which is a tumour marker for ovarian cancer, is raised only in 50 per cent of early ovarian cancers and is raised even in benign conditions. So the best way to identify women at high risk that their ovarian tumour is a cancer is to use Risk of Malignancy Index (RMI), which is a scoring system using ultrasound features, CA125 value and menopausal status. Using this RMI, one can triage patients into low risk, moderate risk or high risk for ovarian cancer. Low-risk women have a less than 3 per cent risk of cancer and can be managed by the gynaecologist; medium-risk women have approximately 20 per cent risk of cancer and are managed in a cancer unit. High-risk women have more than 75 per cent risk that their ovarian tumour is cancer and are best referred and managed at a cancer centre for the most optimal outcome and survival. The writer is former Consultant, Department of Obstetrics & Gynaecology, the
PGIMER, Chandigarh
A wake-up call Symptoms which should alert one to visit the doctor for investigations for ovarian cancer: These symptoms are significant to investigate if they are: Symptoms not specific to but suspicious of ovarian cancer Examination findings which require referral to a gynaecologist to rule out ovarian cancer Risk factors to be taken note of
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