Wednesday, April 25, 2018

My favourite productivity tools

The tools we use often dictate how productive we are. These days with the internet, computers and smartphones, a large number of tools are available that help us to be more productive. It is important to make use of the right tools to track what you’re doing and what your priorities are.

To enable me to be efficient, I have a set of tools that I use. Before I describe them, I need to state that I use an iPad Pro 10.5” as my primary and only computer. I have an Apple Keyboard and Pencil to go with it.

1. Mail: This is the default email client that comes with iOS. I try to get to Inbox Zero just before lunch and just before I leave for home. Any email that comes to me gets treated in one of the following ways:
  • Respond - where someone is asking me for some information
  • Make a to-do on a Trello Board - where I need to do something that is more than just a simple email response
  • Move to the appropriate folder - all FYIs
  • Forward to SaneBox - things that I need to follow up on later (I will also bcc a copy to SaneBox in some cases. More on this in a bit)
  • Delete - unimportant stuff
In the first two cases also, the emails go to a folder. My Inbox is only for things that have not yet been acted upon.

2. SaneBox: How many times have you sent an email to someone asking for some information and then after a few days realised that you did not receive a response? Well, SaneBox is a tool that helps with such dicks who don’t respond in time and need a dozen reminders. All you need to do is to bcc an email to a later point in time (6 hours, 1 week, 3 months and so on) and you will get an email back at the designated time where you can check if you received the response or not. There are in-built tools in Gmail and other mail clients that offer similar functionality.

3. Trello  A to-do list on steroids. Multiple to-dos form a list. Multiple lists form a board. You can have multiple boards. Lots of great features like reminders, notes, sub-lists, collaboration, attachments, moving tasks around. A must-have. All my long term and short term goals are in different places here. Annual, Monthly, Weekly and Daily tasks are decided here. Many times, things go from here to my calendar to ensure I carve out time for what I consider important.

4. iCal: Well, I don’t think it’s called that anymore. But I am used to calling it that so I will just stick with iCal. It’s basically Apple’s calendar tool. It offers syncing with Google Calendars. A host of other features that any decent calendaring tool would have.

For us to work in a consciously productive manner, the tools we use are critical. Good tools simply life so much. I know of people who don’t use anything beyond email. Gosh, I feel sorry for them and more so, for whom they work with.

Saturday, April 21, 2018

My Dialysis Wish List

Recently, I was asked what the top three items would be on my wish list for dialysis. I was pretty sure about the top one item. Portability, without doubt. I miss the ability to travel for long periods without resorting to in-centre four-hour sessions. Currently, travel is restricted to a maximum of two nights away from home. If, under some rare circumstances I do have to travel for longer durations, I would need to go to a centre. With NephroPlus dialysis centres in many places now, quality of dialysis is no longer a concern. However, the whole aspect of having to restrict my diet and fluids and laying in bed awake for four hours during a session seems rather painful.

A portable dialysis machine

However, pressed for two more items on the wish list set me thinking. What were the other problems for me in dialysis? Considering that I get daily, nocturnal sessions, I can’t even say less diet and fluid restrictions because I have none. 

Water treatment comes to my mind as a huge pain. First off, the water treatment plant occupies a large space in my home. There are minor issues once in a way. I need to put it on to fill up my treatment water tank once every day I dialyze. So, if there was a way this could be eliminated in some manner, it would be a huge relief.

A water treatment plant

The third thing I would like is for the machine to be able to detect how much water to remove during my session. This is a big problem for me on dialysis. It is also a major problem for many other patients. Figuring out the dry weight is a challenge that has not as yet been resolved satisfactorily. Currently this is done only by indirect methods like checking for oedema, breathlessness, blood pressure, incidence of cramps and hypotension etc. 

There are machines available that operate on the principle of bioimpedance that claim to be able to estimate the amount of excess fluid in the body but their accuracy is questionable. I am sure there could be some way by which the dialysis machine could check the density of the blood and figure out how much excess fluid is there and set the Ultrafiltration target appropriately.

Dialysis has not seen much innovation over the past several decades. Apart from the NxStage System One that addressed the problem of portability, hardly anything else has been released. What the dialysis industry needs today is a major shake-up of things and bring in a wave of innovation that truly addresses the several problems we patients face on a regular basis.

Sunday, April 8, 2018

Prevention is better than (no) cure

What is the best way for a government of a country like India to roll out Universal Healthcare

There are two aspects to consider here. Why would any government roll out Universal Healthcare (UHC)? The straightforward answer to that question is that it benefits the citizens of the country. Food, shelter and healthcare are the three basic necessities for all human beings. If they lack access to any one of them, then it is unfortunate. 

In democracies unfortunately, the main reason UHC is rolled out is that it is a great way to win votes. Since healthcare is such a basic need and it is something that can cost a lot for individuals, making the State provide healthcare in some form is a nice way to become popular and then possibly win the next election.

Now, the two different reasons for which UHC is rolled out - being good for the citizens and becoming more popular can result in two very different approaches to implementing this policy. While the former would entail doing what’s right in the long term, the latter would dictate doing what’s right in the short term.

Allow me to explain.

One very reasonable metric to measure the effectiveness of UHC is the number of Disability Adjusted Life Years (DALY) saved for every dollar spent. DALY is a combination of number of years lost due to premature death and number of years lost due to illness. It is a better metric than simply early death because being diagnosed with a critical illness also causes loss of productive years of one’s life and this also needs to be included in assessing any impact of such programmes.

Now, if you want to get the best bang for the buck, that is, get more DALY saved per dollar by the scheme, it makes much more sense to invest in preventive healthcare than treating diseases already diagnosed. There are several cases where this has been found true. For example, take someone who is diabetic but is not yet diagnosed. The amount of money you would need to spend to diagnose it and then counsel and ensure they take proper measures to delay or prevent other long term complications of diabetes would be much lower than the money you would spend on treating the diseases they would get after some years of undiagnosed diabetes. 

However, when you look at the political considerations, a new metric would make more sense - DALY saved per dollar before the next election. Using this metric, treating people with currently diagnosed conditions would give you the best returns and not prevention. This is because the effects of preventive healthcare can only be long term. These effects also do not have any definite, perceptible and measurable results at the level of an individual. Unfortunately these are the outcomes that can impact elections.

If you keep political considerations out of the picture, in the long term, preventive healthcare yields the best returns. This is truer when it comes to several diseases where there is no cure but only expensive maintenance therapies like kidney disease. 

Sunday, April 1, 2018

Conservative Care must be recognised as an acceptable treatment modality for ESKD

Treatment of ESKD is based more on improving numbers rather than quality of life. There is a mismatch between what doctors consider important and what is important to patients. The recent SONG initiative that was instituted to determine the outcomes that should be tracked in any research going forward found a huge disparity between the outcomes that matter to the two groups when it came to hemodialysis.

While the top two outcomes that mattered to patients were Ability to travel and Dialysis-free time, the doctors thought mortality and hospitalisation rates were most important. This should be a wake up call for medical professionals. They’ve got it so wrong.

As a patient, I can fully relate to the findings of the SONG initiative. To me, how long I live is not as important as how well I live. To keep a patient alive using any means, irrespective of what it takes is a horribly wrong way to think about things. 

Far too many people with ESKD die in ICUs hooked to a million different machines, with broken ribs as a result of resuscitation efforts. The last sounds they hear are of panicking doctors and nurses and beeping machines. Compare this to a peaceful death at home surrounded by your family, listening to soothing music and quietly slipping away. What would you prefer? This is a question everyone in ESKD care needs to ask themselves.

Conservative care should not be a bad word. It should be treated as an acceptable alternative. Let us face the reality. Many people do not want aggressive treatments at some point in their life. Many people cannot afford dialysis. In India, 85% of people who need dialysis do not get dialysis because of the lack of access to treatment or lack of funds to pay for the treatment; often both. Currently, since nobody talks about conservative care, these people are abandoned, left to die. 

Take patients who can afford treatment but are old and frail and have a host of co-morbidities. Today’s healthcare system will try to squeeze every rupee they can from the family and try to treat the patient with aggressive modalities like dialysis. Families do not want to be burdened with the guilt of not ‘doing everything possible’. What happens as a result? The patient is made to suffer the pain of dialysis for days and weeks without any consideration for what their wishes are. I have seen people hate every second of the treatment but yet have to go on, hoping that the end would come soon. Why this torture?

Conservative care needs to be discussed with the patient and the family in both the above circumstances. It needs to be presented as a reasonable option. It should not be looked upon as an ‘abandonment’ but as an acceptable alternative. There should be four treatments discussed with them - hemodialysis, peritoneal dialysis, kidney transplant and conservative care. They should be made to understand that conservative care will involve visits to the doctor, blood tests and other investigations and medications which would ease symptoms. It should not be seen as a ‘lesser’ option.

However, I am gloomy about this. In a country where even a therapy like Peritoneal Dialysis is not discussed with newly diagnosed patients, will Conservative Care even be considered? Until healthcare systems become more mature and genuinely more patient-centric, thousands of ESKD patients will continue to die violent deaths in ICUs when a peaceful passing at home could easily have been made possible.

The Supportive Care Continuum

Treatment of ESKD should not be only about treating numbers. Treatment should be of a unique individual with differing needs. Unfortunately in our country, we have only about 1500 nephrologists for a population of 1.2 billion whereas in developed nations, the ratio is much better. This leads to an unrealistic focus on only major problems from a scientific perspective. These are problems that can increase the likelihood of death or hospitalisations. 

However, patients are often more bothered about other things. For dialysis patients, things like itching, lack of sleep, pain and depression could be really bad. These do not come in mainstream medicine that is practised by nephrologists. So, little attention is given to these symptoms. However, in the patient’s mind, these symptoms often take a disproportionate amount of attention. Eventually their Health related Quality of Life (HRQoL) plummets. In India, this is very rarely talked about, forget about measuring and treating it.

This image (taken from the Executive summary of the KDIGO Controversies Conference on Supportive Care in Chronic Kidney Disease) beautifully illustrates the continuum of supportive care.

The blue area is regular care which could include things like dialysis. The green area is supportive care - care that treats symptoms that may not be life-threatening but very important from the patient’s perspective. As you can see, supportive care should be there right from the beginning. Typically, the needs for supportive care increase with duration of time on dialysis. After a certain point of time, hospice / palliative care is the only thing that is recommended, not aggressive therapies like dialysis.

Unfortunately this aspect of treatment is grossly ignored today. This results in low HRQoL scores of patients which if measured, would scream and say that some important things are not being addressed. The focus of treatment should be the patient, not the patient’s blood test reports. Of what use are normal blood tests if the patient is not feeling good? It is important that the patient feels better and is positive about his health. Most patients value things other than what their doctors think they value. This is a fundamental truth in today’s healthcare being practised around the world.

This is like the famous Birbal story where there was a man looking for a ring under the lamp post even though he had lost it elsewhere just because there is more light there. It’s time we looked in the right place.

The curse of Social Media

There’s a lot of noise these days about the problems with special media platforms especially Facebook. This follows the revelation that the data of about 50 million users was leaked to a company, Cambridge Analytica who surreptitiously exploited a feature in Facebook. To me, the problem is not even the issue concerning the privacy of data that everyone seems to be targeting. I don’t care if any company has access to my Facebook data. There is nothing of significance or secret there. 

I am more worried about being uncontrollably hooked to the platform. I recently heard a Masterclass by Psychologist Adam Alter as part of my meditation app, Calm, where problems with platforms like Facebook was explained. I was thoroughly impressed with the class. I recommend it to everyone.

Social Media takes up so much of our attention. The trouble is the continuously scrolling feed and the lack of a ‘stopping cue’. When you read a newspaper or a book, there is a well-defined end point. In the Facebook timeline, there is none. This means that you can perpetually keep scrolling. 

Another problem is the instant gratification. When you post something, you get a high when someone likes or comments. You keep checking from time to time how many likes and comments you get. One thing that I have noticed is that the attention span of people is getting lower and lower. Post a picture and you get many likes in a short amount of time. Post an article and the numbers of likes reduces drastically. People just don’t have the time to read through anything even slightly long even if it’s something important or interesting.

The like and comment features cause another disturbing change in you. You start valuing yourself based on these. You look for such positive affirmations for yourself in these shallow ways.

And then there’s the FOMO (fear of missing out). You don’t want to miss anything that’s happening in others’ lives.

I recently removed all social media apps from my phone. I really enjoy the few minutes of boredom from time to time - in the elevator, in the car, between meetings, while walking down the hallway of my office. All these periods used to be spent looking into my phone screen earlier. I haven’t yet completely deleted my Facebook and other social media accounts. I can still access them from my iPad (which is my primary work computer these days).

I have begun hating Whatsapp as well. What started as an instant messaging system has now become an instant disturbing system. When I am dong something important, I get a million Whatsapp notifications about what others consider important and I often don’t give a fuck about. I have turned notifications off recently. I have got a lot more peace in return.

At the end of the day, it all boils down to whether you have control over social media or whether it has control over you. If used well, it can do some great things like putting you in touch with long lost friends. If not, you can end up becoming obsessed with it and letting it take over much of your life.

(If you made it till here, congratulations, you have a fantastic attention span.)

Tuesday, March 27, 2018

ESKD Global Health Summit 2018 - UAE

(Cross posted from The Atypical HUS Alliance Action website.)

I was invited to participated in the 2nd ESKD Global Health Summit at Sharjah organised by the International Society of Nephrology (ISN) from the 18th to the 20th of March. The overarching objective of the summit is “Increasing access to Integrated ESKD Care”. Specifically, the objective of this edition was:

“… to design a global strategy to better understand the global differences in ESKD care, support ESKD care development in LMIC, and consider the ethical, financial, and cultural issues involved in the expansion of ESKD care.”

LMIC is Low and Middle Income Countries. LMICs are seeing the fastest rate of rise in ESKD incidence.

About 90 people attended the summit and the participants were predominantly nephrologists from various parts of the world, many of them stalwarts in the field. There were also a couple of nurses and a representative from the World Health Organisation.

From time to time, the ISN gets requests from various LMIC about implementing ESKD care services as part of an initiative to implement Universal Healthcare (UHC). The ISN wanted to design a 5-10 year strategy to improve Integrated ESKD care especially in LMIC. LMIC have peculiar challenges. The goal was to arrive at a plan to overcome these challenges with respect to ESKD care. 

Eight working groups were created to deal with different aspects of this goal. Each participant was assigned to two of the eight working groups several months before this summit. Preparation started many months in advance and documents were drafted on how to deal with each aspect. Each working group then presented initial plans and the working groups then met independently to brainstorm on key questions and issues that remained and finally presented a broad plan to the entire group.

The entire exercise was very insightful. It was very useful to hear about situations specific to countries from around the world.

There were many themes that occupied centre-stage. One was patient-centred care. Everyone agreed that patients should be included in any such exercise. They had invited a couple of patients other than me but they could not attend. 

Another central theme was that “PD first” seemed to be a very good policy especially if PD fluid could be manufactured locally. Many nephrologists were unhappy about one company controlling the entire PD market and expressed a hope that this would change.

Preventive mechanisms for kidney disease was obviously the best option. However, access to healthcare facilities was the biggest challenge in many countries. There was a discussion around having a pyramidal structure where Primary Healthcare facilities work on basic detection of kidney disease and then referrals happen to Secondary and Tertiary Facilities for follow ups and treatment.

This entire exercise is going to result in some strong policy recommendations and a series of journal manuscripts that will address this major problem.

One important takeaway for me was that whenever any such scheme is rolled out, the goal should be to touch and save as many lives as possible. This is not very good news for people affected by a rare disease. The drugs that exist for these rare diseases are so expensive that the expense incurred on treating one patient could potentially save hundreds of lives with other conditions. Honestly, I am ok with this. This is a reasonable way to go about such initiatives.

The ISN must be commended for including patients in this very important summit and I hope they continue to engage with patients in all such programs. After all, they are the affected party.  People and groups involved with matters concerning patients should, in all arenas and at all stages, strive to increase meaningful insight and discussion with “Patients Included” in projects, policy, clinical settings, and research initiatives.

Saturday, March 17, 2018

Why not thrice weekly HDF compared to Daily Nocturnal HD?

I recently blogged about why Daily Nocturnal HDF wasn’t recommended to me by some experts in home HD. One of my colleagues at NephroPlus, Rajesh, asked a very pertinent question in the comments: “But why go for long durarion and frequent HD when you can get the benefits of HDF with shorter and less frequent sessions?”

Great question, Rajesh.

The reason is fluid removal. Any type of dialysis primarily performs two functions - toxin removal and fluid removal. Since the kidneys are not performing well for someone on dialysis, the excess toxins and fluid in the body need to be removed. This is done by dialysis. Now, while the toxin removal rate can be improved by various methods like increasing the blood flow rate, dialysate flow rate, using a better dialyzer etc., the fluid removal is constrained by one important factor that cannot be changed - the body’s ability to lose fluid without having side effects.

The average human body can lose only about 400-500 ml/hour during dialysis without experiencing side effects. Removing fluid more rapidly could lead to symptoms like muscle cramps, hypotension etc. Whichever modality of dialysis you choose, however high or low you set the blood and dialysate flow rates and whichever type of dialyzer you use, you cannot change this fundamental characteristic of the human body.

By doing daily, nocturnal HD, you are giving more hours of dialysis which means you are removing the fluid over a longer duration which reduces the rate of fluid removal to well below this 400 ml/hour limit. This enables you to drink significantly more fluid and yet not experience the side effects of rapid fluid removal.

Monday, March 12, 2018

SC ruling on euthanasia and living will does not go the whole hog

The Supreme Court in a recent ruling made passive euthanasia legal and also legalised the process of creating a living will.

Let us first talk about the passive euthanasia part. This tackles the issue when there is no hope of recovery. This is a good thing. This should have been a no-brainer. Unfortunately it has come too late. Many people have suffered for years in pain due to the absence of such a law. Of course, there might have been many cases where the doctors and family might have quietly pulled the plug to save the patient the agony of being a vegetable waiting to perish. Good for them.

However, an important question still remains. What can be done when there does exist a treatment but it is worse than the disease? Yes, there could be betterment down the road but the path is torturous and full of suffering. If the patient would like to decide that they do not want to endure that pain and that they would like to withdraw from treatment, they should be allowed to do so. Currently, even after this ruling, this is still illegal which is a travesty of justice.

We’ve all heard of cases where patients in ICUs have been recovered, but at what cost? They were left with broken ribs due to the resuscitation attempts. What are the chances of such processes helping recovery? Many people die in ICUs after spending several days inside with tubes and needles in every conceivable space. Wouldn’t it have been better to die in peace at home surrounded by your family? Medications exist which can make the end peaceful despite several health issues.

I am not advocating that make the above method the default process. All I am saying is give the patient the choice. That is the least we can offer.

This brings me to the living will. A process has been defined to execute the living will and you can read about it here. There is one major problem with the process outlined. It is so laborious and complicated that I doubt if anyone will actually undergo the hassle. The process for the will to be enacted when the patient actually becomes comatose is also so long and arduous that it looks to me like the process will take weeks if not months. The purpose of the living will will be defeated by this process.

I understand the court’s concern while drafting the process. The concept of the living will can be misused by people with nefarious intentions. But I don’t  think the solution outlined is the answer to this problem.

However, like every such major change, iterations are inevitable. It is too much to expect to get things right in ther first attempt. Let us hope that the last word on this has not been said yet.

Sunday, March 11, 2018

Daily Nocturnal Hemodiafiltration - Yay or Nay?

There’s a lot of buzz these days around Hemodiafiltration (HDF). Various studies have shown that HDF offers better clearances - even of middle molecules, the recovery time is shorter and so on. This results in better outcomes. Ther main principle behind HDF is that the clearance is due to convection rather than diffusion (which is the method by which toxins are cleared in regular HD).

I had been advised to switch to HDF as well by various people. I do daily, nocturnal hemodialysis currently. I dialyze for seven and a half hours, five times a week. After hearing all the buzz, I thought maybe I should also try HDF. Daily nocturnal HDF would be a killer combination - the benefits of longer duration and a higher frequency along with convective clearances that HDF gives.

Or so I thought.

I checked with some experts in the area of more frequent, longer duration dialysis. There was a consensus that for those who do more frequent, longer duration dialysis, there is enough toxin removal. In fact, some stuff was removed so well, phosphate for example, that it had to be supplemented (like for me). The levels of Beta 2 Microglobulin and homocysteine were also normalised. There was also a fear that the things you don’t want removed like amino acids and drugs would be removed. They did not know anyone on this modality. Some also felt that the cost of the treatment would shoot up unnecessarily and water quality monitoring would need to be bettered.

All this put Daily Nocturnal HDF in the “not recommended” category.

Good for me.

Saturday, March 10, 2018

Tajdaar e Haram by Atif Aslam

I have been listening and appreciating Atif Aslam for ages now but did not know that he was called Atif Aslam. Recently however, I chanced upon this song, “Dil Diya Gallan” from the film Tiger Zinda Hai and was totally mesmerised. What a masterpiece!

I started researching about the singer and had this Aha moment. “Ok, no wonder it is this guy.” And then, as is usually the case, I started finding all the songs sung by him. In this process, I ran into this gem, “Tajdaar e Haram”, originally sung by the Sabri Brothers of Pakistan. Atif Aslam sang this for a performance for Coke Studio (Pakistan).

Here is the video of the Coke Studio performance:

Here is the original by the Sabri Brothers:

Saturday, March 3, 2018

How much into the future does the work that you are doing now impact?

I recently read an article (unfortunately I don’t remember where and so, don’t have the link) where this question was asked. Leaders of organisations should typically be doing work that impacts a few years into the future. This would include strategic planning for the direction in which the company is headed, putting processes in place, doing things to protect the culture of the company and so on. Of course, there would times when there would be pressing tasks that don’t impact that far out. But, leaders should spend a large amount of time doing things which impact the company way into the future.

If the leaders of a company spend a majority of their time on dealing with day to day issues then there’s something wrong and that needs to be corrected. A team should be put in place that takes care of these things and the leaders must mainly work on process, direction and culture. They should ask  this question time and again to remind themselves of the significance of their role. It is easy to get caught up in the daily grind and flood of emails that usually hit their inboxes on a regular basis. Time should be carved out and put on the calendar to ensure that this does not come in the way of the long term impact their work must have.

Friday, March 2, 2018

The Lighter Side of Dialysis by Peter Quaife

Peter Quaife was the founding member of the band, The Kinks. He was on dialysis from 1998 to 2010. When Quaife went for his dialysis sessions, as a way to kill time during the four hour sessions, he started sketching cartoons about dialysis. All these cartoons were collected and published as a book called The Lighter Side of Dialysis.

What a great way to pass time on dialysis. The cartoons have been made available as a free download some time back on this website which is of the Pete Quaife Foundation.

My favourite cartoon is this one:


Wednesday, February 28, 2018

Rare Disease Day

The last day of February every year is observed as Rare Disease Day. A Rare Disease is defined as one that affects fewer than 1 in 1,500 to 2,000 people. There are estimated to be about 7,000 rare diseases. There are about 300 million people living worldwide that have a rare disease.

The trouble with rare diseases is that often they do not get much attention as the number of people affected by each disease is very small. This means that very few companies would consider developing treatments for a rare disease. When a treatment is discovered or developed, the pricing must be high enough for it to make economic sense for those investing money in it since the number of patients that could potentially be treated is very low.

Many rare diseases are of genetic origin and appear early in life. About 30% of children affected with a rare disease die before they turn five years old.

My primary disease Atypical Hemolytic Uremic Syndrome (aHUS) is classified as an ultra-rare disease. A disease is defined as an ultra-rare disease if it affects fewer than 20 per million population. aHUS is estimated to affect 2-3 people per million population. The problems that exist with rare diseases are often compounded with ultra rare diseases.

Currently, most Indian rare disease and ultra-rare disease patients do not have access to what is considered the standard of care in developed countries as the Indian population cannot afford the extremely expensive treatments that are available elsewhere in the world. What Indian patients hope for this Rare Disease Day is to be given a fair shot at a normal life, to get access to a life-saving treatment that is available elsewhere in the world and we are denied because of two accidents - one of genetics and the other of geography.

Friday, February 16, 2018

Cross infections in dialysis centres - the hows and the whys

Cross infections with the Hepatitis C virus have become a menace in many dialysis centres. Hepatitis B and HIV viral cross infections are also possible though rare. A viral cross infection occurs when a virus is transmitted from a carrier of the virus to someone who did not carry the virus. Viruses multiply rapidly and typically, if the body is unable to fight and kill the virus completely (which happens rarely and that too, before the virus has got a chance to multiply significantly), the new individual becomes a carrier of the virus as well.

The likelihood of transmission of these viruses in hemodialysis centres is greater because blood is coming out of the body and is passed through the dialyser (artifical kidney) and the bloodlines. Reprocessing of dialyzers and bloodlines increases the chances of this transmission because these items are taken to a reprocessing area where they are washed, sterilised and prepared for next use for the same patient in his or her next dialysis session. In this process however there is a chance of some blood from another patient’s dialyzer and bloodlines entering this set. Though this should not ordinarily happen, the chances are not zero.

Most dialysis centres have separate dialysis machines and reprocessing areas for those infected with these viruses. But this does not preclude the transmission of these viruses due to one major problem with the way in which blood samples are tested for the presence of these viruses before deciding whether the patient is a carrier of the viruses or not.

When the virus first enters a person’s body, within a few weeks, the body develops antibodies to the virus which try to fight the virus and kill it. These antibodies are easier and cheaper to test than the virus itself. So, most tests make use of testing whether the blood of the patient contains these antibodies or not. If it does, it is assumed that the virus also must be there. If not, the patient is certified as a non-carrier of the virus.

The trouble with this method is that typically the body takes a few weeks to develop these antibodies. So, if the patient has acquired the virus recently, even if this test is done, he or she could be certified as a non-carrier of the virus. What this means is that even though the patient is a carrier of the virus, he or she is going to be treated like a non-carrier allowing the chance of other true non-carriers to be infected since the carrier is going to be treated on the machines and reprocessing areas meant for non-carriers.

There is another more reliable test which actually directly tests for the virus itself. This test would give a positive result soon after an infection has happened. However, this test is many times more expensive than the antibodies test. Very few people can afford this test. Also it is not enough if only you pay for the test. This works only if every patient starting dialysis in the centre gets tested by the same method because you can get infected by another patient who decides not to do the more accurate test.

This is a major problem in dialysis centres in much of the developing world today. Research needs to be done to figure out ways by which the cost of the more accurate test can be reduced to bring it within the reach of most patients. Otherwise it would be very difficult to contain this problem.

Wednesday, February 14, 2018

Ayushman Bharat: India takes another baby step towards Universal Healthcare

India took another small step towards Universal Healthcare this month. The government announced the Ayushman Bharat scheme. The highlights of this scheme are:
  • Allocation of Rs. 1,200 for converting 1,50,000 health centres to comprehensive Primary Healthcare Centres covering a range of basic services
  • A National Health Protection Scheme (NHPS) where the government would cover 10 crore families for secondary and tertiary healthcare services 
Within a short span of time, several criticisms of the plan were voiced including the low fund allocation for the NHPS, lack of focus on strengthening the Public Healthcare system and the scheme being tailored to benefit private players.

The Niti Aayog held a press conference to clarify many of the misgivings. They stated:

1. There would not be any co-pay to be borne by the beneficiaries
2. There would not be any cap on the number of members of a family
3. The scheme would be funded jointly by the Centre and the states similar to how such schemes are regularly funded

Additionally, several clarifications were issued about the premium amount estimated, the modalities and timelines of roll out etc.

Whichever way you look at it, India has now firmly embarked on its Universal Healthcare journey. We may eventually reach true, genuine, uncapped, equitable and fair healthcare coverage for all citizens in many decades from now. But we have started on the journey. This is an important step in any country’s life.

Granted, there are many things that need to be fixed. There are many lacunae. But then, Rome, they say, wasn’t built in a day. To fix India’s healthcare system is an infinitely more complex task. Such a mammoth task would be impossible to get right in one shot, at one go. This is something that can only be done in an iterative manner. Implement things, figure out the kinks and then fix them in the next iteration. This process has to go on till a smooth system is established.

That is not to say that we must not learn from the mistakes of other countries. Worldwide, it has been proven that public healthcare systems are the ones that work the best in providing Universal Healthcare. India must strive to bolster its public healthcare system. The current, highly inadequate 1% of GDP that is spent on public healthcare needs to be tripled to reach somewhere close to global averages. We all know however that for our public healthcare infrastructure to reach optimum or even adequate levels of quality and access will take some time. In the meantime, we must continue to find other means to achieve partial success in some areas of healthcare.

Prof. Vivekanand Jha, Chief Medical Officer of NephroPlus and Executive Director of The George Institute for Public Health, India, summarises this best in an article in The Wire:

“Irrespective of the pros and cons, the most important contribution of the finance minister’s Union Budget speech is that for the first time, healthcare seems to have come to the forefront of public debate arena in India. It is important for all the stakeholders to ensure that this conversation stays alive. It is impossible to say how long it might take to reach a stage where access to essential equitable healthcare becomes a reality for a majority of the population, but we seem to have made a start.”

Sunday, February 11, 2018

Make the Karni Sena pay for the damage

I saw Padmaavat yesterday. Nothing in the film depicts the Rajputs in a negative light. What was all the fuss about? What exactly was the Karni Sena protesting? Why did the four states that banned the film do this? What kind of mockery have we turned ourselves into?

Everyone seems to have forgotten the way the Karni goons announced rewards for Deepika Padukone’s nose. We have also forgotten the damage done by them to public property and the way they held the film makers to ransom. They have apparently taken back their protest after watching the film and have announced their support to the film offering to help to release the film.

This would have been funny had it not been so completely ridiculous.

I can guarantee that no government is going to take any action on the Karni Sena. They will be allowed to get away scot-free. This is not the denouement that we should allow. Stringent action must be taken against the thugs of the Sena that unleashed their mindless and unjustified fury against the film makers. They should be made to pay for the damage caused. They must be made to compensate the producer of the film with the revenue that the film has lost. Take the revenue of states with a similar population and make the goons pay this to the producer. If this is not paid within thirty days, arrest the office bearers of the Karni Sena under sections similar to those when compensation is not paid as ordered by the court. 

The judiciary must make an example out of this incident so that no lunatic fringe group can ever dare to commit such a crime again.

Friday, February 9, 2018

The Lodha spa pool fraud

My parents and I moved a few months back into a flat in an apartment complex called Lodha Bellezza at Kukatpally in Hyderabad. One thing that we were excited about was that every flat in this complex had something they called a ‘spa pool’ in the main balcony next to the living room. In the plan showed in the brochure they cleverly omitted the word ‘spa’ and only had the area shown as ‘pool’. Which leads me to the question, “What exactly the hell is a spa pool?”

A quick search on the internet revealed the following: Typically, spa pools refer to small, heated and jetted pools that are built into the ground.

I pictured myself spending many relaxed evenings in the spa pool. I drew mental images of hot water jets massaging my aching backs after a tiring day at work. Except that the said spa pool was neither heated nor jetted. Ok. Small inconvenience. Who needed hot water in a spa pool in hot Hyderabad, I said to myself. 

When we moved in we learnt that most people in the apartment complex had demolished the spa pool and converted the balcony into a deck. We decided to wait for some time and then decide. It’s been about four months since we moved in. How many times have we filled the spa pool? All of once. Filling it took hours. We couldn’t figure out how to empty it. We were asked not to leave the water in it for more than two days. We called the maintenance guys who never showed up despite repeated reminders which was strange because they were very prompt in attending other complaints. Slowly water began appearing in our bedroom walls. We then called the maintenance guys and shouted at them and ensured they came and emptied it promptly. The seepage stopped.

We are soon going to be demolishing the spa pool. So much for the excitement. To be fair, the apartment complex is a very nice place with very good facilities. The place looks like a resort with all the landscaping. The swimming pool, gymnasium and all other sports facilities are all world-class. It’s only the spa pool I have a problem with.

When I look back, I think this was a brilliant marketing gimmick used by the builder. This is something that would excite everyone and be utilised by no one. What a waste of money first in building it and then in demolishing it. 

Tuesday, January 30, 2018

The deception of thin crust pizzas

To me pizza heaven means a Margherita  A nice and light, chewy crust, tomato and salt based pizza sauce, mozzarella cheese, fresh basil leaves and olive oil baked to perfection in a high temperature oven. For me, each of these is important on its own. That is why, thin crust pizzas feel like I’ve been cheated. There just isn’t enough bite. It’s almost like you’ve put them in your mouth and barely had time to relish the flavour and its done. A crust gives some time to enjoy each of the flavours. And then there’s the crust itself. Some thickness allows you to savour the comforting feel of the bread, the craters and the nice smell of fresh bread. Why give all this up?

I think the trouble with the regular crust which people give up in favour of the thin version is that it is not done properly. I remember the early days of pizza chains in India. The pizzas would have such horrible crusts that my jaws would ache with all the chewing. Some chains haven’t changed. That is probably why people started opting for the thin crust is my guess.

A good crust is not that easy to make. Especially for the pizza chains which have bastardised the art of making pizzas to perfection. It needs love and attention to detail. Well, I have not mastered the art yet. Quite far from it, actually. But I can tell a good crust from a bad one. Here’s an example of a good crust:

You need to have those craters which basically mean the dough is light and airy and that air bubbles have formed inside. This is what makes a good pizza crust. In my humble opinion.

Thursday, January 25, 2018

Mindless Karni Sena

Padmaavat releases today. In escalation of the violence perpetrated by the lunatics that go by the name Karni Sena, yesterday in Gurugram, a bus carrying school kids was attacked. What is shocking is that the BJP state governments that do not want to release the film are more worried about how to stop screening the film than on how to control the rioting.

PM Modi may be too big to comment on this ‘minor’ issue. What is he and his party doing to protect the citizens who are doing nothing illegal by deciding to watch the film? Is the film going to be screened in the BJP ruled states? What a clever strategy these people have devised. Stand by in silence while the Karni Sena thugs go about vandalising property. Cinema owners would be scared to screen the film fearing damage to their property. That way, a ban would be achieved without any court, government or police intervention.

People accuse the Modi government of being more talk than action. This is one case for sure where this is turning out to be true. 

Two things must be emphasised here. The belligerent rascals from the Karni Sena haven’t even watched the damn film. What on earth are they protesting? Hearsay? And for a moment, let us assume that there is something in the film that they find objectionable. Who is going to decide what can be shown in a film, written in a book or expressed in a blog? Everything can be found objectionable by someone or the other. Where is this going to stop?

Why is the government sitting silently and watching the drama? There is no point in making nice-sounding speeches at international summits when back home, this kind of shameless pandering to mindless fringe groups continues.

Tuesday, January 23, 2018

Mineral and Bone Disorders - the most perplexing problem to deal with in long term dialysis

As you know, I have been on dialysis for the last twenty and half years. I have seen many co-morbidities during this period but none so complex and difficult to get a handle on as Mineral and Bone Disorders (MBDs). This problem has confounded many senior nephrologists as well and a steady-state s very difficult to achieve. 

To address MBDs you need to balance the levels of Calcium, Phosphorus, Parathyroid Hormone and Vitamin D. Calcium is a very important element and is essential for the proper functioning of our body like the muscles, nerves and bones. So evolution or God, depending on which side of the divide you are on, created the Parathyroid glands that generate Parathyroid Hormone and the sole function of this hormone is to regulate Calcium in the blood. When this gland senses that the level of Calcium is going down in the blood, it releases more of this hormone which gets Calcium from the Calcium stores of the body - the bones, and releases it into the blood. The opposite happens when the level of Calcium in the blood becomes high. 

Vitamin D, on the other hand ensures proper absorption of the Calcium that is a part of the food we take.

The trouble with kidney disease is that the functioning of the Parathyroid glands is affected. This results in a condition called Secondary Hypeparathyroidism (as opposed to Primary Hyperparathyroidism, a condition where the glands are affected inherently) which releases excess Parathyroid hormone and this causes the Calcium levels in the blood to go too high. Over a period of time, this results in bone loss as the hormone is leaching too much Calcium from the bones.

The solution to treat this problem is to take a class of drugs known as calcimemetics like calcitriol which work to reduce the amount of the Partathyroid hormone in the body. However, the danger of this drug is that it can at times reduce the level of the hormone too much and this condition called Low turnover bone disease can be even more dangerous than what it is trying to treat.

Add Phosphorus to the mix and you have a cocktail heady enough to get even the most experienced nephrologist, not to mention, his or her patients left feeling tizzy.

I have been struggling with this condition for many years now. Every month I need to test my Calcium, Phosphorus and iPTH to decide what combination of drugs I am going to be on that month. There never is a steady state. We have tried every combination in the book and out of it but have yet been unable to get our heads around this conundrum of MBDs.

Monday, January 22, 2018

Making an annual plan

I recently chanced upon an article that talked about planning an ideal year. I have found my life meandering recently and this article resonated with what I wanted to do. It basically encourages you to make a plan for the year and then taking steps to fulfil the plan. 

Making the plan involves listing down the various aspects of your life that are important to you like work, family, financials, hobbies, spirituality etc. and then writing down your annual goals for each of these aspects. The key is that each of these goals should be measurable and time bound. Then you plan a month at a time breaking down the annual goals and setting goals for the coming month. You conduct periodic reviews to see how you’re doing. I highly recommend reading the article.

Many of us go about life in a completely reactive manner. We let things happen to us and then act accordingly. This is a poor way of living, in my humble opinion. I believe that each of us must aspire to live a life that is dictated by what we want to do with it. This may seem obvious but funnily, we don’t do things this way. We go about life in an ad hoc manner - typically juggling work and family without doing anything else about the other aspects of life that we consider important. The excuse is typically that we don’t have the time.

After many years, when we look back to see what we have achieved, we might not feel very good about ourselves. We might feel that we have prioritised completely wrongly and we could have done much more with our lives than make progress only on the work, family and financial sides.

We, as human beings have so much more potential to achieve things. We need to identify what we truly care about and then work towards making progress on those fronts, year by year, month by month, day by day. Only then can we look back and feel good about the life we’ve lived.

Saturday, January 20, 2018

An unintended benefit of having a small appetite

As I wrote some time back  I stopped taking antacids recently. This has reduced my appetite quite dramatically. I have now lost about eight and half kilograms. I continue to put on less fluid weight between dialysis sessions.

Yesterday I realised that I got one more benefit from this - eating mindfully.

I am a big fan of idlis. I frequent this place called Govind’s in Hyderabad which serves really delightful idlis. When I had a ravenous appetite, I used to gobble up a large number of idlis quickly, one after another. I did realise at some point that I was eating too fast and that I should slow down and try to relish every morsel. I tried but inevitably after a couple of bites, I would becomes fast again.

Yesterday, I knew I was going to be able to eat only one plate. I ate slowly, relishing every bite, feeling the taste and texture of the idli and the chutney. I enjoyed the experience.

Many of us probably go about life in such a rush that we don’t actually enjoy each moment even though we are doing something we purportedly like. Our minds are occupied with a hundred other things and we don’t realise that we have gone through our favourite activity without actually being present. Meditation has helped me realise this and try to change it from time to time. I have a lions way to go but I at least I have begun the journey.

Being present and being active in the moment giving our full to the present activity enables us to live a life more fulfilling.

Sunday, January 14, 2018

Having a blind uncle is better than having no uncle at all

Many states in India have begun offering free dialysis to its citizens. Some are under the Central Government’s National Health Mission Free Dialysis Program  Some schemes already existed before this program. Some of the schemes are flawed in their design and some are flawed in their execution. A few of these schemes are implemented very well.

It takes a lot of effort, knowledge, asking the right people for advice and most importantly, intent for a government to do things the right way. Not all schemes have got the details right. What constitutes a well-designed and well-implemented Dialysis provision scheme? I would list the following items as some of the important aspects to consider if genuinely good outcomes are desired:

- Providing thrice weekly dialysis. Some schemes offer only twice weekly sessions. World over, the minimum recommended dialysis frequency for dialysis patients on MHD is three times a week. Anything more is welcome. Anything less can be called half-baked at best

- Including ESAs, IV Iron and other medication like phosphate binders and blood pressure medication. Without this, it is very difficult to maintain good anemia management and effective management of co-mobidities like Mineral and Bone Disorders, Left Ventricular Hypertorphy etc.

- Including blood tests and other investigations. If this is not done, it is like shooting in the dark. How can clinical outcomes be managed if they are not even measured?

- Implementing a comprehensive Renal Replacement Therapy program by including Peritoneal Dialysis and importantly, Kidney Transplants under the purview of the scheme

- Having a comprehensive prevention program where governments target population segments that are considerd high-risk such as diabetics, hypertensives and implementing an effective program to manage such conditions to prevent or at least delay progression to kidney disease

These are only some of the aspects which must be included.

However, it is very difficult to expect a government who is not sure of whether they would be continuing for another term to think long-term and to be able to effectively come up with such an ideal program. After all, such as program would require a lot more funding, effort and infrastructure to be able to implement.

In these circumstances, should no program be implemented at all?

We have a saying in Gujarati that loosely translates to “It is better to have a blind uncle than no uncle at all.” In this context, it means that it is better to have a flawed program than no program at all.

Perfection is difficult to achieve at first. Implementing a flawed program and then continuously keep making changes to the program to include the above items in the program might be a better idea.

Rome, they say, wasn’t built in a day. Implementing a Free Dialysis Program in a country like India is arguably even more complicated. Let us take it one step at a time. Let us make one improvement at a time.

Saturday, January 13, 2018

Should constrained public healthcare systems spend on expensive maintenance therapies?

I often envy countries that have public funding or a mature healthcare system that takes care of expensive drugs such as Eculizumab that is the only known approved treatment for my disease Atypical HUS. I often wish that my country too had a healthcare policy that could provide this drug to me.

India’s public health spend is a little over 1% of GDP. This is way below the world average of about 7%. The National Health Policy 2017 has targeted to increase this to 2.5% of GDP.

Yes, this is low as well but we must remember that India is a severely resource-constrained country and we need to spend every rupee after a lot of thought. There are several basic areas where India lags behind world averages when it comes to healthcare statistics such as Maternal Mortality Rate and Infant Mortality (which, thankfully are getting better, see here and here). When many Indians do not have access to basic healthcare, should the government spend on expensive things like the drug Eculizumab? Many times, questions are also raised on maintenance therapies like dialysis.

I have had several discussions with people on this subject. I have usually taken the line that the government should spend on dialysis along with other aspects of healthcare like the ones mentioned above. 

The overarching theme of any such decision would usually be the number of lives being saved or affected. Kidney disease affects about 10% of the world’s population and about 1% require dialysis or are on a transplant. aHUS affects 2-3 per million population. With such small numbers, do such therapies really merit funding by the government? The US Government spends about 7% of its Medicare budget on dialysis which accounts for less half a percent of its population. We, in India, some would argue would be better off spending this money on primary healthcare rather than maintenance therapies that are often life-long with poor outcomes.

Unfortunately, healthcare policy has to be driven by the number of lives affected. There just is no other reasonable way. Would you rather spend crores of rupees to save one life or use that money to save hundreds of lives? That is the unfortunate truth today for India. India cannot afford to spend on secondary and tertiary healthcare when the primary healythcare system itself is in shambles.

This means that I will probably have to just wait in the hope that another cheaper drug comes out to treat my condition and becomes available in India. This means I will not be able to get a kidney transplant any time soon. This is a little difficult to digest as I see so many people around me getting a kidney transplant and not needing dialysis any more. But, at the end of the day, it is what it is.

Friday, January 12, 2018

The agenda for the 2019 Lok Sabha elections

I saw a report a couple of days back about the BJP planning a ‘mahayagna’ to appease the Gods for the 2019 General Elections. We are also seeing the BJP and the Congress bring Hindutva into the agenda for the Karnataka assembly elections. Rahul Gandhi has been on a temple-visiting spree and is having people in the Congress talk about him being a Brahmin. Is this really what people in the country care about?

I often wonder why political parties speak about issues that are irrelevant to people’s basic needs like food, shelter and clothing? That’s actually a wrong question. The real question is why political parties speak about issues that we feel are irrelevant to people’s basic needs. One thing’s for sure. Politicians are all shrewd, self-serving people. So, why then do they talk about things that we feel are irrelevant to people?

I think the rather troubling answer is that politicians would not talk about things that are irrelevant to many people. To many Indians, things like religion and caste are probably more or at least as important as food, shelter and clothing. Why else would politicians make these factors so important in the days leading to an election?

I think people value their sense of identity, their sense of being a part of a larger something - a community, a caste, a religion irrationally. They do not realise that at the end of the day these things don’t matter much at all. These things are probably fictitious structures created by our species centuries ago and have no real significance whatsoever. However, they have been ingrained so deeply in our psyche that we find it impossible to believe otherwise.

Politicians understand the way people think. They know that they don’t have to win arguments made in television debates to win elections. All they need to do is to win the minds of people which have so many demons, that they can pick and choose what suits them best. So, despite all we know, the agenda to the 2019 Lok Sabha elections may not be the so-called development plank that PM Modi and the BJP keep talking about. It may well be about emotive issues that don’t actually matter at all.

Thursday, January 11, 2018

Dialysis patients, be thankful if you have a supportive family

I have been very lucky to have such a supportive family in my journey with kidney disease. I realise that everyone is not so lucky. I have seen all kinds. Some are extremely supportive, some not so much. Some, unfortunately treat the patient like a burden. No wonder so many dialysis patients are suicidal. A supportive family is a blessing. If you have one, be grateful. 

I don’t blame families for getting tired of the disease. Kidney disease can be frustrating both for the patient and the family. While there is no doubt that it is more unforgiving for the patient, families often are affected quite badly as well. Typically, it is the closest caregiver who is affected the most. Accompanying the patient to dialysis thrice a week, making sure medication is taken, going to a range of doctors from time to time, hospital admissions and blood tests, all take a toll on the family member as well.

Then there is the important aspect of expenses on the treatment. In India, where most expenses are borne out of pocket, this can be quite debilitating for a family’s finances. Many families have their entire life’s savings wiped out in a few years. This increases the frustration of the family especially since the patient has not been cured by the time this could happen. It is an unending moral dilemma. Should the limited resources of a family be spent on a maintenance therapy with the patient becoming worse over the years with increasing co-morbidities? All this turmoil can cause a lot of mixed emotions among the family. Many family members take their anger out on various unrelated targets like hospitals, doctors, other family members, colleagues etc.

Patients can try and ease some of the trouble by becoming as independent as possible. Patients should try to get back to work if possible. They should take control of their health. They should ensure that they take their medication as prescribed on their own, follow their diet prescription diligently and even try to go to the dialysis session on their own. All this helps ease the burden on the family. Patients must keep telling them how much they appreciate the family’s efforts in helping. Indians are not very vocal about gratitude. Merely feeling grateful is not enough. Making it known is equally important.

All this helps to build a relationship that is not dysfunctional but mutually supportive and appreciative. This can go a long way in adding to the patient’s feeling of well-being and eventually make it easier to deal with the ups and downs of this disease.

Tuesday, January 9, 2018

Why more people don’t do nocturnal home hemo in India

I often wonder why more people don’t do nocturnal home hemo in India? To many people, it might seem it is about the cost. I don’t think this is true. I know many people on dialysis who are far more wealthy than I am and yet do not pick this modality.

I think it has a lot to do with fear. Most people have either had a bad experience in the dialysis centre or hospital where they get dialysis or have seen someone else have a bad experience. They fear that should something like that happen at home, how will they be taken care of? They feel that the absence of an emergency support system at home, there could be a high risk of death. The emergency management infrastructure in India is also woefully inadequate. An ambulance could take long to get to you. In the US it is different - help comes to you within minutes.

What many people don’t realise is that if you’re doing daily, nocturnal home hemodialysis, the chances of anything going wrong during treatments are very low - far lower than something similar happening in the hospital. The reason is that the dialysis is much gentler. The blood flow rate and ultrafiltration rates are very low and this dramatically reduces the risk. The risk is not zero but it is low.

Another possible reason is that people do not want to take the hassle of taking care into their own hands. Currently, they show up at the dialysis centre and everything else is done by the team at the hospital. I am not sure if people like the control they get when they bring dialysis home. This is also possibly one of the reasons some people, even if educated about Peritoneal Dialysis are loath to adopt that modality despite the tremendous freedom it gives them. 

The benefits of doing long duration, more frequent dialysis at home are enormous. Freedom from most diet and fluid restrictions, flexibility to fit dialysis into your schedule rather than the other way round, better quality of life, better longevity and lower incidence of comorbidities are only some of them. The low adoption of this modality is there even in countries where people pay little or nothing out of pocket for healthcare. This lends credence to my  assertion that this has to do with things other than affordability.

This is sad because a lot of people are missing out on the better life possible due to this amazing modality.

Wednesday, January 3, 2018

Science and Religion

The debate between science and religion has been raging for centuries now. I have always been fascinated by this debate. Having been an extremely religious guy for a long time, I was always intrigued by arguments from both camps and have endlessly debated this in my own mind without ever having reached a conclusion.

Religion is this constant theory, unchanging with times, based on dogma, based on one or more religious texts. Science is open to change. Scientific theories are discarded all the time based on new evidence or in favour of theories that can explain known phenomena better. Both the approaches have their advantages and disadvantages.

Science is completely free of dogma. If you are able to prove a new theory sufficiently well, it is accepted and the old theory is discarded. Religion refutes all new theories and claims that science will eventually come around and accept that religion holds the key to understanding the world. 

Science is the easy pick among the two for many. You believe what you see. You believe what is proved by reasonably accurate experiments that can be replicated in different circumstances. For example, it is a well-established fact that the species Homo sapiens originated somewhere in Africa and then moved to the rest of the world. This is based on a number of excavations that have proved a number of traits like the size of the species, the tools they used, the food they ate etc. The trouble is let’s say you believe that and refute religion’s claim about the origin of man (based on which religion you believe, this could again be very different). After a decade, some archeologists excavate some site in Australia and find relics of ancient man that pre-date the African relics. Suddenly all hell would break loose. Science would have no hesitation in accepting that the old notion of the African origin of man was flawed and that the species actually existed before this in Australia.

This is true for every aspect of science. Medicine keeps changing every day. What was supposed to be good for the heart one day is found to be not good the next day. The anemia target range for those on dialysis keeps changing faster than a dialysis patient’s dry weight!

Where then does that leave someone who discards religion in favour of science? 

On the other hand, religion does not care about evidence. It claims to be the ultimate truth. It does not need evidence. This is a difficult pick but if you have deep faith in a particular religion, you don’t need to worry about the changing evidence. You rest in the belief that what your religion says is all true.

What about some incontrovertible evidence then about things that are firmly established in science? For example, most religions say that the earth is flat and that the sun revolves around the earth? This is clearly not true. The US would not have day when India had night if this was true. This is something that can never be proved wrong. Where does that leave religion?

So, this debate will continue to rage forever. While religion relies on faith, science, on evidence. Take your pick but be ready to challenge yourself whenever a troubling question arises.

Tuesday, January 2, 2018

Being grateful

I have been meditating for ten minutes every morning for the last many months now. I use an app on my iPhone for this. For me, this practice has been a life-changer. It has completely changed the way I think. In today’s exercise, the topic was gratitude. I have read multiple articles about how gratitude helps to be happy. But in today’s exercise, I was asked to actually practise it. The ten minute exercise was really beautiful.

I have so much in my life to be grateful for. I think the most important reason I have for gratitude is my parents. This may seem cliched. But I honestly did not feel this way until not so long ago. Today, I cannot thank them enough for all they have done for me. Right from ensuring that I have a good education to providing for every comfort I had during childhood despite being a family with limited means, my parents have been such an important part of my life. During my journey with kidney disease, they have been such solid pillars of strength that I can never imagine having come so far without their support.

I am also grateful for NephroPlus and Vikram and Sandeep who have been a part of this incredible journey. I credit Vikram for being the main reason NephroPlus has reached such great heights. His amazing foresight, his legendary networking and his ability to never lose sight of the big picture are things without which this company could not have achieved what we have been able to achieve today.

I can safely say that without the ability to do home hemodialysis, I would not be alive today. I am so grateful to be able to do this type of dialysis. Much of what I am grateful for is thanks to this modality. I am able to eat and drink pretty much what I what. I am able to work, exercise and travel freely. I am able to do so many things which are due to the benefits of home hemo.

I am so thankful for having reasonably good writing skills. This has enabled me to write this blog which has brought me so much appreciation. I was able to be a part of the NephroPlus journey only due to this blog. Had Vikram not found this blog while researching for kidney disease in India, we would never have met. Who knows, he might have started something else in healthcare. This blog has made it possible for me to touch so many people by encouraging them to lead full lives despite being on dialysis.

There are so many more things that I have to be grateful for - friends who have given me such an important perspective of life, my brothers who have always been there in times of need, my teachers who have played such an important part in shaping my thinking, my doctors who have constantly endeavoured to enable me to live the life I wanted to live.

I am really thankful for all these blessings in my life today.