Sunday, September 22, 2013

Next Patient-Ailing Earth: A physician's dilemma



This write up was born out of an attempt to prepare a script for a lecture on "Infiltrated Earth drive-management strategies" for students of a national institute of information technology.

The first power point slide shows a patient Mr. Prithvi waiting his turn outside the physician's clinic. Generally most Indian names have a meaning and Prithvi means the Earth. Now I am not sure how Mr. Prithvi appears to you. I am trying to use him as a metaphor for a system under trouble and am just hoping the audience will be able to visualize him as I see him…a virus afflicted system. The Earth to my mind mirrors a similar system on a macrocosmic scale also afflicted by a virus that refuses to coexist in harmony with it.

To begin with let me just portray him in realistic terms as a human Mr Prithvi, who waits his turn outside the physician's clinic.

We often need suspension of value judgments to comprehend or tolerate illustrations of real life that do not portray real life as such. Some of the connoisseurs of art are habituated experts at this sort of a thing but I am apprehensive my present college audience might be a majority who simply like to call a spade a spade and may not wish to enjoy these multiple unreal metaphorical snapshots of an object (in this case Mr. Prithvi).

The ability to suspend our value judgments may be an essential prerequisite to survival in a postmodern world filled with multiple versions of truth. Coming back to Mr. Prithvi…he has a worried look in this first power point slide. Tests have revealed that his system is inoculated with a virus. The next slide shows his eyes. Although I call them his eyes I project an icteric sunset with a few avian silhouettes in flight. Now some people may not like this technique of abstraction although in academic power point meets I find this is generally accepted, as most of the audience in these meets must have habituated themselves to such abstractions. The discussion that follows rests heavily on the ability of my audience to appreciate these abstractions.

Till now Mr. Prithvi is projected in their minds as a jaundiced human but soon he shall be transformed into the Prithvi, a living giant macrocosmic organism that harbors countless Mr. and Ms Prithvis just as Mr. Prithvi Harbors the countless viruses (microcosmic entities) that have inoculated his system at an earlier unknown date.


Approach to system trouble shooting-

The next power point projects just this heading. Many of these seemingly arid slides are actually tremendous vibrant displays of colorful information once the presenter makes sure that he is able to connect to all the skull tops (brains) of the audience and tap the vast treasure house of visual data compressed within them (in short trigger their imagination).

Disease localization-this sub heading appeared below the previous heading magically with a mouse click.
Well …the approach is rather simple…in one word its localization…anatomic and etiologic localization…don't get perturbed by the medical jargon…they are too simple even to pose a rudimentary challenge to our understanding. In simple terms we need to know where the problem is (anatomic localization) and finally why is the problem (etiologic). These are the only two things clinicians are worried about before they can move over to managing the problem. Its akin to solving a computer hardware problem where one needs to decide which component is malfunctioning and if so why.

In the next slide we move into the innards of Mr. Prithvi's system and I project Mr. Prithvi's gigantic macrocosmic form, a satellite image of our planet that hits you when you open google earth for the first time. We are trying to do an ultrasound scan of Mr. Prithvi's liver and as I click my way into the innards of the satellite image, the scanner transforms its macroscopic images into deeper microscopic ones and gradually we confront an area in the liver that looks lush green, forested and slightly forbidding as the sunsets.
As the pathologist continues to scan through the normal lush green tissue she suddenly encounters an abnormal area of bizarre concrete structures, skyscrapers and flyovers interspersed with a scantly amount of green parks. This is it…a big cancerous growth in the liver that is often labeled "city". An interesting feature of the wiki mapia that wasn't there with google Earth, allows all H viruses to post their own tags to various patches of the Earth. One ubiquitous tag is "Land for Sale"; very often visible in most green patches bordering the city. This tells us how and where the tumor is spreading next.  
The H. viruses inside Mr. Prithvi are very much active and thriving in the artificial settings they have created for themselves inside Mr. P's liver. So what next…


The pathologist keeps sliding Mr. P's liver biopsy sideways on the satellite microscope and one can discern vast areas of the Earth's green ravaged by the urban dwellings the virus needs to stay secure from nature. "I don't think one can do much with this amount of spread," she comments. The physician ever happy to get a diagnosis at last rubs his hands in glee, "Aha…just as I had suspected…the anatomic diagnosis is carcinoma liver (that's where Mr. P's problem was all along and the etiology is the H. Virus that inoculated it sometime back (a few million years perhaps as carbon dating tells us?). The virus has mutated over the last few centuries to give rise to this malignant mass and this is why we have the problem.

Now what…where do we go from here? As a physician it is not very often that one deals with a patient that is of such gigantic proportions. A patient that is home to this physician and other countless H. viruses that continue to breed in its innards.

All humans are born physicians by virtue of an ownership right on their own systems (bodies) that so very often go wrong and need trouble shooting. Most humans' worldwide are aware of the cancer that is ailing Earth and there have been plenty of solutions proposed from all quarters of our H. virus population. We shall review them in the next few slides.

Viral Clearance  

Ordinarily as physicians we always like to treat the cause but in this particular instance we can't, as we are the cause. However it is interesting to think experimentally what might happen to the Earth if by some quirk it manages to pack off all humans to some outer space theme park. In this slide you can see how the other organisms from the microscopic algae to the Elephant (who have unlike humans never harmed the Earth till date) gradually take over our cities, how the malignant concrete eating into the green is reversed by the green closing in on the cities, as their algal walls crumble under the constriction of wild vines. Yes, viral clearance is a worthwhile solution as any hepatologist battling H viruses with interferon and nucleoside reverse transcriptase inhibitors will tell you although coming across a complete remission once the tumor is advanced may yet be unheard of. One thing is clear however, we H. Viruses are not yet ready to leave, not before we have riddled a few more holes into the ozone layer and the heat begins to get on our nerves along with the oceans rising and also there's this other tiny problem of finding another planet. Space tourism is costly at the moment and most H. viruses will have to wait at Earth till a suitably accessible outer space real estate becomes feasible.

Chemotherapy and radiotherapy are too drastic measures and a violent onslaught on their property may not be appreciated by most H viruses who increasingly seem to prefer peace.



 Tumor cell Apoptosis

The only other solution is natural apoptosis that still hasn't caught on among the cells of H viruses.  Throughout ages they responded to their natural instincts craving more security than they really needed which often was because some of them demonstrated more power than they really had.
Most H viral economies are either modeled around exploiting the Earth's natural resources (variously termed production, development etc) or exploiting each other (labeled competition). H viruses needed to protect themselves from the forces of nature, the Earth's immune system that would attack them from time to time. Over the ages H. viruses have not only successfully silenced the natural forces but have also exploited nature to serve their own ends so much so that they face this peculiar predicament of having to witness the demise of the very natural world they set out to protect themselves from little realizing that it was also a larger part of the place they called home.

As long as development continues even if sustainable it is not going to benefit the Earth although it still may benefit a few more humans. All this development, this economic growth leaves the Earth poorer of its natural resources every day. We need to return to Earth, embrace its trees even as tech park builders chop them off. We need to give up our cars, shift our homes closer to walking distances from our place of work and shopping centers. Our houses need to be less opulent and huge to reduce the natural resource consumption that is necessary to maintain the grandeur. We could eat locally grown
produce instead of the perennial exotic branded fruits lined up in global malls flown across the other end of the globe burning fuel for our round the year consumption.

Can we all arise from our seats in this grand auditorium and come out and seat ourselves in the floor of the large empty hall from where one can also look at the lush flora of this campus and listen to the birds chirp. No I guess not… any way I suspected I was getting carried away in the last bit with the sudden burst of unintended cliché.

For the cancerous growth to stop we may need to go against our natural instincts of self preservation and our overtly powerful response to every fear from nature and return to a non developed closer to Earth existence, of our cave dwelling near animal ancestors. I am sure it won't be acceptable to most of us city-bred humans. I can already hear the protests and voices of disgust. "Here we are working towards developed world status from a measly third world existence. All our lives we have been striving towards our inherited dreams of that nice car and plush house and now that it finally seems to be coming true with the country's GDP peaking at an all time high, you are asking us to give up all our dreams…"

No…I guess this is asking too much from this generation. At present we can only look at means to palliate the Earth as it dies and for ourselves hope that we discover another Earth like planet sooner than Earth's last gasp.    

Friday, September 20, 2013

Bhopal visual Potpourri: A post modern tourist’s diary



The current sample chapter below on ‘Bhopal’ is a flashback of visuals encompassing a 5 year journey but feel free to do this in just more than 5 minutes (by the time you finish reading this).
If you are using windows 25 and trying to scan the images coded below in English alphabets with your ‘n’ MHz clock speed CPU then it is likely that your Microsoft photo editor will be able to translate this alphabet code into images but the visuals may often appear to be in charcoal (perhaps because of a bug in the new Microsoft photo editor getting in the way).
Oh! by the way if you are a human reading this (the previous line was meant for robots) you don’t need to worry about translating the images because your software is different and we are yet to figure it out but lucky you...just sit back and let the alphabetical syntax flow into your eyes and go beyond your occipital cortex to generate as much visual semantics your brain allows.

Visual 1:

You are on your car that has taken off from Bhopal toward the nearby cave paintings of Bhimbhetka and you are transported to10, 000 BC...the birth of modern asynchronous information communication technology (henceforth ICT).
As soon as your car crosses the suburbs of Bhopal and the forests adjoining the national highway (also known as ‘main road’ in local terminology) you spot a few rock outcrops atop a hill jutting out amidst a wooded forest (you may or may not bother to compare it with Stonehenge especially if you haven’t seen either) and it may or may not be love at first sight but you might like to stop at the quaint little coffee shop at the railway station just before your car enters the forest. You will find a few bridelia retusa trees (locally called Kasai) there. http://upload.wikimedia.org/wikipedia/commons/5/5d/Bridelia_retusa.jpg  Feel free to relax and pause for awhile under its shade.

Visual 2:

The cave paintings were made by the earliest human users of ICT who felt the need to communicate asynchronously with their brethren particularly at times when they may have felt they wouldn’t be around for the day. Soon these images were translated into symbols small enough to fit into a bhoj patri (something like a papyrus) and here you see the same symbols on the page that you are reading now and if you have read till this line you are pretty good at decoding ‘post-modern’ cave paintings really. As you troll through the caves and marvel at the paintings on the rock surfaces you may like to pause at a picture of a lion being hunted by a pack of cave men. Would be good to know which one of the paintings you liked the most.

Birds of Bhopal:

Visual 3:

After you drive from Bhopal toward Sanchi for about 50 kilometres and reach a place called Salamatpur, take the right turn to the Sonari stupa from the main road and then go along the dirt road (known locally as kuccha road) till you reach the way to the stupa and instead of following the regular path to the stupa take a left turn and after a time you shall arrive at the foot of a bowl like valley.

I have marked it here on the wikimapia:


You shall find another area marked Lavanya green orchids and one marked trek to the stupas. The best birding area is actually sandwiched between these two marked areas.
The visual you may treasure in your memory of this place (depending on the season) is a flock of rosy starlings in the early hours of the morning just before you set off climbing the forested hill forming a part of the bowl like valley in your bid to reach the Sonari stupas within the forest.
You also see the usual list of birds that one can spot around most places in Bhopal. This one copied below was compiled by Shomi Gupta ( a chartered accountant and environmental activist) and if you are in Bhopal you will be really lucky to have her on your nature tour.
1.         a) Asian paradise flycatcher ( pair:  female & adult white male)
2.         b) Asian paradise flycatcher ( mother & 3 subadult male juvenile)
3.         Golden oriole
4.         Large cuckoo shrike.
5.         White breasted kingfisher.
6.         Great tit
7.         Mini blue kingfisher
8.         Oriental white eye
9.         Common iora
10.       Green bee eater
11.       Crested bunting
12.       Partridge
13.       Grey francolin
14.       Red rumped swallow (taking mud for the nest)
15.       Black drongo
16.       Red wattled lapwing.
17.       Blue rock pigeon
18.       Hoopoe.
19.       Rosy starling.
20.       Common starling
21.       Silver bill munia.
22.       Pond heron.
23.       Tailor bird.
24.       Purple sunbird.           
25.       Warbler (unidentified)

Herbivore list

1.                  Langoor monkey.
2.                  Barking deer

Carnivore list

1.                  Civet (road kill)
Incidentally the Asian Paradise Flycatcher is the state bird of Bhopal (although it is very much prevalent in the Indian subcontinent from Himachal to Sri Lanka and you can see the beauty in this picture here:http://upload.wikimedia.org/wikipedia/commons/d/dc/Asian_Paradise_Flycatcher-_Male_at_Himachal_I4_IMG_3011.jpg and here: http://upload.wikimedia.org/wikipedia/commons/f/ff/Terpsiphone_paradisi_-near_Amaya_Lake%2C_Dambulla%2C_Sri_Lanka-8.jpg
Visual 4:
On your drive back through the main road don’t miss the food at Astha Dhaba (Dhaba is a way side restaurant). You may never have noticed such large whole wheat flour rotis taste so soft. As you drive further toward Bhopal a keen bird watcher at the back of your car may suddenly cry out OMG! Stop...Stop...look at that amazing flock of ‘woolly necked storks’ to your left. These are just drop dead gorgeous, tall large birds. Take a look here: http://upload.wikimedia.org/wikipedia/commons/f/fd/White_necked_stork_%28Ciconia_episcopus%29_21-Mar-2007_7-37-51_AM_21-Mar-2007_7-37-52.JPG
One of your kids remark, “...they don’t look like ‘fully naked storks.’ What did you say their name was again?”


Tree watching:

Visual 5


For those of you who are likely to visit Sanchi and not take the detour to Sonari (obviously have no qualms on being labelled modernists) there are other natural pleasures in store.
Most of the Sanchi Stupa area is adorned by ‘Manilkara Hexandra’ http://www.outreachecology.com/landmark/LTI_pix/LTI_SinglePho_640/c050_LTI_SinglePho_640.jpg
If you are planning to adorn your garden with this tree, beware of its slow growing nature as it would take decades to reach the size you see in the picture above. This is an interesting tree of the ‘sapotacae’ family which is currently just used as a rootstock for its more popular cousin in India ‘Manilkara Zapota’ imported from its native dwellings in southern Mexico, Central America and the Caribbean. The Spanish name ‘zapota’ has been Indianized to ‘Sapota’ and further popularized as ‘chiku.’

Many places in Bhopal are named after imposing trees and one of them is a ficus common in most parts of India. ‘Barkheda’ an ubiquitous bus stop or place name in Bhopal derives from the ‘Bar’ tree. http://upload.wikimedia.org/wikipedia/commons/0/07/Banyantree.jpg It is prevalent everywhere in India and perhaps called ‘Ficus Benghalensis’ because the botanists at the time who provided its botanical name happened to have their office in Bengal. There is a large beauty occupying the sprawling lawns of a museum in Sanchi and should not be missed especially when it is fruiting (which is most times of the year).

Peepal khedi is another common bus stop in and around Bhopal again derived from another common road side tree, ‘Ficus Religiosa,’ popularly known as Peepul. This is also the tree below which Buddha sat meditating toward enlightenment (some say even the name Buddha was derived from the fruit of this ‘Bodhi’ tree, which is another name for the same tree).  A fruit from the original Bodhi tree in Bodh Gaya was taken to Sri lanka and still stands there as the oldest flowering plant in the world. Its picture here: http://upload.wikimedia.org/wikipedia/commons/b/b1/Mahabodhitree.jpg appears no different from the Bodhi tree you shall find in the campus of our institute, the People’s College of Medical Sciences, People’s University.

I guess i shall end here (albeit abruptly) and leave the other originally planned diatribes on integrating medical education and practice through post modern constructs such as ‘evidence-based-medicine’ and moving from androgogy to heutagogy (as far as medical education in concerned) for another day. Enjoy your tour of Bhopal.

Monday, September 16, 2013

Chapter 69 THE LETTER FROM A VIRUS 2-5



Virus 2


Our ancestors arrived like Columbus and started knocking on the doors of the native population which resided peculiarly deep within the earth in a nucleus. Our ancestors might have opened a hidden trap door and descended down an escalator to a huge sphere with multiple small windows. Clothes weren't allowed and so his majesty, took leave of HBsAg and HBeAg, shed off his royal robes and climbed into the sphere, as naked as a DNA. There, he was greeted by the local chromatin population and shown around.
Great place! Thought the king and settled down, had children, another life, and another kingdom. Now we Hep -B viruses don't enter into sexual relations that easily but prefer to replicate our own DNA, so the king sat to meditate.
His deficiencies and gaps were filled and he became a covalently closed circular DNA (or you could say he was totally covered up in a termite mound). The CCC-DNA was extruded out of one of the windows and then the mound broke into three pieces of slithering snakes, ready for transcription. It proceeded with the synthesis of a minus strand followed by a plus strand and finally we had baby HBVs.
The first threat of an external aggressor appeared around this period. It wasn't anything to do with the natives within the nucleus who were pretty docile and never troubled us. It was the ocean predators.
They were probably the other inhabitants of this vast body of earth in areas, which still remain unexplored. They started off by attacking our children. Dear little baby peptides dressed in colorful epitopes loved playing in the beach. We never thought they would draw the attention of those detestable classes of MHCs. They would play with our children and hold them up in the air from time to time. Little did we know that this would be a signal for their CD-8 (seedy-ate) ally that is until the first bombardment.
The hepatocyte shores went up in flames. Fire spread rapidly, lighting up the usually dark jungle silhouettes. Across another corner, in a dim glow, one could barely discern other dark shapes getting down from odd looking boats, starting to drill the earth with perforin drillers and pouring poison into those drilled perforin channels .
The ravages we have survived along with our coveted land are a tale often repeated. I guess, every society has its persecutors, bombardments and yet life begins anew. Many of our brothers devised increasingly cunning ways of eluding our seedy attackers. It’s been a topic of research among you humans (some of us refer to you as Demons/Gods).
Mechanisms of persistence of Hep-B viruses in chronic carriers, is a hot issue, the complete unraveling of which might push the final nail into our coffins. However, before that I seriously believe and wish to convey that your body of earth itself is in jeopardy.


Virus 3


Mechanisms of HBV Persistence


Some of our HBV brethren left the hepatocyte shores and swam with the strong oceanic currents to seek refuge in other greener pastures...kidneys, brain, testes, pancreas and the like. The seedy cells couldn't pursue them all the way to these places apparently dissuaded by micro-vascular anatomic barriers, which surprisingly are lacking in the Hepatic sinusoids.
Other than this, some of us tried to fox the MHCs by mutating the epitopes in our babies to evade recognition by seedy eyes. Then there were some peculiar natural factors, which came to our rescue as well. The MHCs we learnt were essentially polymorphic and all MHCs were not equally bad and some of them just played with our kids. The MHC II came perched on macrophages and these giant whales required a daily rubbing of Vitamin D oil on their surface, to actually stay active.
Recently some of your people discovered a mutation (T to C at 352 position) in the Vitamin D receptor gene that might lead to inadequate activation of these killer whales. These whales also love to eat with a particular sauce (mannose binding lectin) and again this was successfully adulterated.
Another ploy that we had to devise was born out of sheer desperation in our continued struggle against the seedy cells. One night, hordes of our guerilla forces attacked a fleet of passing PBMCs (peripheral blood mononuclear cells), climbed onto their ships and took over after a bloody battle. Their wireless system with which they used to summon more and more seedy cells were effectively silenced.


Virus 4


Carcinogenesis


Other avenues of survival opened up in our very homes inside the hepatocytes. The local people we noticed were surprisingly immune to seedy attackers. They had disagreeable features but in the interest of survival we started marrying into their communities (effectively, integrating with our host genomes). We married and multiplied into a modern cosmopolitan society. Gradually, we lost our food gathering nomadic existence and settled into concrete stable dwellings with equally fine-processed food to satisfy us. Multi-storied buildings started adorning our skylines. Gone were the palm trees, green fields were encroached by collagenous cement that hardened with each passing day. You could almost hear the muffled cries of earth as it stifled over this new overpowering burden.
Since the early part of this century ...we had continued to rebuild and regenerate after each and every seedy attack. However regeneration and degeneration can leave ugly scars. Presently we have had the unfolding of another interesting scenario. The seedy missiles having been silenced, what we have now is simply growth and more and more growth.
Some of us have begun to see through all this growth and realize our days as well as that of the earth are numbered. It's only a matter of months now. That is, if we can't devise new ingenious methods to escape our present predicament. Life is generally defined by some universal traits, which we suspect might be present even in you humans. It might be present even in the myriad subatomic particles that make up our relatively puny bodies.


Virus 5


The earth which we live in seems similar to your earth and we are accumulating enough evidence that it’s inside you humans where we might be residing (like your concept of a living earth). Therefore, this uncontrolled growth of our civilization might be the death of your body and therefore this desperate communication (By the way, is the growth of your society too progressing exponentially - really, this concept of parallel universes is fascinating).
Life grows as an expression of its universal traits, chief among which is a perennial dissatisfaction with the present and an insatiable urge to change, replicate and evolve. Look at our evolved bodies, added up from myriads of subatomic particles and look at your body (our earth) even more highly evolved and yet yearning for more. More love, more growth, more reproduction both in thought and form ... yet survival is the name of the game and we have evolved over the years, just to survive. I am confident some of us will manage it even in the wake of this global cancer.
As night falls, a few dark silhouettes among us have been noticed to wade out with their rubber dinghies into the deeper waters of a darker ocean, hoping against hope.... someday ... another tunnel, another universe, fresh green rice fields bordering dense forests. Clouds you'll notice, too exhibit living characteristics of a non-linear replication, summation and accumulation, which from time to time, bursts into a downpour, catching you unawares in the rain. We wanted to live like a cloud but ended blowing up in smoke.

Yours truly,
Hep-B alpha