As a Patient, Don’t forget.

In Uncategorized on May 23, 2010 by sushrutayan

All of us know now that ‘Technological fineness is deteriorating human skills’. In Medicine we have started seeing this trend lately. In our hospital (tertiary care) we get many patients who have already been seen by other doctors.When I want to examine such a patient I have to expose the abdomen, I can make out that he/she has not been examined properly before. This means that the earlier inspection was wrong, resulting to wrong diagnosis and hence wrong treatment–with poor outcome of patient not feeling better or getting complications arising out of that problem.
For this, a Patient should insist thorough examination from doctors, proper diagnosis and then proper treatment.We should never get treated without a diagnosis, all patients have right to know their diagnosis, methods of treatment, pros and cons.

Be careful.


The Elephant and the Blind Men

In Uncategorized on May 23, 2010 by sushrutayan

“It is astonishing with how little reading a doctor can practice medicine, but it is not astonishing how badly he may do it”
– Sir William Osle

That was quite a busy day for me. While working as a –fulltime senior consulting general surgeon , in a public charitable trust hospital, which happens to be a premier neurological institute in central part of my country, we have a daily outpatient department. In the morning I was busy operating on a emergency abdominal problem. Around 12 noon I came down rushing to OPD as I had another emergency to handle again. Quickly I called upon – Asharani 25 years old female who came from 300 kms distance. As soon as I saw her – a young, fair, sickly woman holding her neck stiff, I asked her to narrate what is wrong with her .She showed me a big 8cmX7cmX6cm size cystic swelling on her manubrium sternum. It was painless when it appeared 6 months back & now it has become painful for one month, it was fluctuant. I had in mind “ a cold abscess” diagnosis. When I asked her about stiff neck, she told me that she is sick for 6-8 months and the neck stiffness is there for about 40-45 days. I asked her to open her mouth and put torchlight there. Hey!! My expectation was correct. There was a big retropharangeal swelling on the right side protruding anteriorly in pharynx. Now my diagnosis got almost confirmed. When I touched her upper cervical spine she was uncomfortable. Stiffness of her neck with stretched stermomastoid on right side was an aftermath of Pott’s cervical spine I could guess. I had to confirm my diagnosis by some necessary investigations. I advised her for X-ray chest, X ray neck AP & Lateral views haemogram, IgG and IgM for TB Elisa, and ultimately CT Scan of cervical spine.

I was in a hurry to go back to OT for the next surgery. I told her to show me all the reports when I came back from the operation. And when I was back the diagnosis was confirmed beyond doubt.

When I asked her why she came so late? The following story was narrated by her relative as –
“Doctor, for last 6 months we have been consulting specialists in a big district place. We took all the medicines sincerely, but she continued to feel ill. We changed the doctors, specialists. She was given cervical traction and physiotherapy so many days, she had received a couple of injections, but there is no relief. We are disgusted with everybody there so came here. Tell us what is wrong with her? No doctor has told us what is wrong with her .

When I saw her previous papers I also got disgusted. She had been practically taken to six senior consultants of different specialities. Amongst them 2 were orthopedic surgeons, 2 general physicians and 2 general surgeons too. None of them had even tried to diagnose her ,instead she had received a list of variety of medicines, injections, traction and physiotherapy etc ,without a Diagnosis.

Her CT Scan was showing evidence of lysis in C2 body, base of odontoid &right lateral mass of C2& right foramen transversum with large paravertebral collection[abscess] with early A-A dislocation [A-A distance-4 mm.] Bilateral minimal epidural collection ,carotid vessels pushed laterally on right side. She was balancing her head on a very thin rim of cortex of her C2 spine; which could have easily given way and she could have became Quadriplegic !!!!,
Similar lytic area in Manubrium sternum with large extra thoracic &smaller intrathoracic collection[abscess] was also reported.
Her IgG for TB was 2600 serounits (strongly positive) .
A young woman with two small children from a country where no doctor can afford to forget about the diagnosis of Tuberculosis and can manage to use all the sophisticated investigations on earth, easily available and also affordable for this particular patient, has progressed to the hilt of quadriplegia. Thanks to her neck stiffness – a protective phenomenon of her body, her inability to swallow properly, else this thin rim could have given way. It would have caused collapse & quadriplegia . Is there any difference at all in a young woman without quadriplegia and a young woman with quadriplegia? I reffered the patient to our hospital’s Neurosurgeon, we got her admitted. Next day her cold abscess from both places was evacuated and posterior fixation of cervical spine was done. She was put on full 5 drug AKT [ Anti kochs Treatment ] regime and a Philadelfia Collar was given . Gradually she got completely alright. We told the relatives how narrowly she is escaped from quadriplegia. They were extremely grateful to us. She went home on 14th postoperative day walking.

But I am terribly disturbed from this incidence!! I presented this patient’s case along with my questions to our doctor colleagues:
1. Do we expect patients to choose their specialists? And tell their diagnosis to them so that they can start treatment ?
2. Do we expect our colleagues not to give medicines to anybody unless they make a diagnosis ?
3. Are these people to be called qualified & expert quacks, though they’re having masters degree in their specialty they don’t take strains for diagnosis and treat the patients? Don’t exert, as these patients are illiterate?
4. Can they justify – their behavior stating a saying – “eyes don’t see what the mind doesn’t know !”
5. Stating that when they saw the patient –
1. It was an early stage of the disease, so they could miss the diagnosis.
2. Or they have a very busy OPD and couldn’t devote much time to take proper history and examination. And when I saw and diagnosed it was a “fully blown”? Case, so very easy to diagnose.

Indeed it was very easy to diagnose for me because I always want to diagnose and then treat my patients. As 5 days before I saw, a physician MD medicine had seen the patient and had labeled her as some cyst??? And referred to me for a surgical opinion !!
6. To blame their tubular vision and forget or blame patient’s relatives.
7. Patient might not have followed a single doctor so how can the doctor know patient’s progress? When she is lost to follow-up. Indeed this patient has changed 6 specialists in 8 months but why?
8. Here I remember an old story of 6 blind men and an elephant. Each one tried to feel the elephant. Whatever part they felt they labeled it as they thought. One who touched the tail said it’s a rope, other feeling leg, said it as tree, one feeling & holding trunk mistook it as a- big tube, one felt Tusks as sword, other holding big ear thought it as leaf and the 6th felt the body , thought it’s a wall. Entire elephant cannot be felt easily and so inability to judge . But blind men had never seen an elephant so they cannot be blamed .

Here these are educated, supposed to have acquired knowledge & having all 5 special+1 common senses and a license to treat. They forgot important principle – that ‘THE PATIENTS ARE OURSELVES’. This one grave incidence tells so many things about the society. Very often we see many, undiagnosed or misdiagnosed but treated (How and for what) patients. Medical knowledge has reached the level of telemedicine and telesurgery is coming in. But there is so much disparity in availability of treatment. There are many social, political, educational and financial reasons.

The fundamental aim of medical art and science has always been to alleviate human pain and suffering. Have we really achieved it? So giving only symptomatic treatment often masks the internal disease & allows it to progress ,creates complications ,increases morbidity & may even kill the patient.

“If it is a question of doubt in diagnosis you may often observe that one man solves the doubt when the others could not, and the way in which one man happened to solve it is this: he applied to the diagnosis of the case some method of examination which the others had not applied” – (Lockwood)

General practice, speciality , subspeciality or superspeciality whatever any doctor may practice the crux of curing any patient lies in two most important aspects of treatment i.e. : 1.Timely diagnosis
2. Timely treatment
We don’t need hi tech machinery or big hospitals to at least suspect the Diagnosis & the cure follows .

As long as any doctor physician/surgeon knows the importance of these two utmost important things patients will not get justice by way of cure, they may become more morbid or die ultimately. I am not pointing towards terminally sick cancer patients or massive myocardial infraction patients whom we fail to save in spite of following the above two norms. I am bringing forth the patient who can surely be saved if and when they get timely diagnosis and timely treatment. In this era of modern sophisticated medical practice so many times we find that The Physician may play the part of a pathogen; it may be by commission or omission . The possibilities & dangers of commission in short can be listed as —–
A- Iatrogenic Diseases….assaults of Modern therapy, injuditious use of therapeutic agents ,thoughtlessly , needlessly & indescriminately given blood transfusions ,exposure to diagnostic & therapeutic ionising radiation. Antibiotics are regarded as the cure for all for the most minor infections & steroid therapy is the refuge of the destitute, it is small wonder that the old maladies are replaced by new manmade ones, multitude of allergens exceeds pathogenic microorganisms in number. The degree of benefit to the patient is not by any means directly proportional to the number of procedures, tests & drugs used.

B——The threat of omission is represented by failure of the doctor to understand patients as people rather than as cases of abnormal physiology & biochemistry. Doctor has to learn to see & treat the person , not the disease .
I compare this tendency of doctors (not to let go any patient without writing a prescription ) with the priests of a temple , where no devotee goes without taking the holy water (teertha). Do they feel scared of refering to other proper specialist ,so that they lose monetorily . Medicine claims the patient even when the etiology is uncertain , prognosis unfavourable , & the therapy of an experimental nature . Under these circumstances the attempt at a medical miracle can be a hedge against failure, since miracles amy only be hoped for & cannot by definition be expected . The radical monopoly over health care that the contemporary physician claims now forces him to reassume priestly & royal functions that his ancestors gave up when they became specialized as technical healers .
The ritualization of crisis , a general trait of a morbid society ,does three things for the doctor. It provides him With a license that usually only the military can claim . The professional who is believed to be in command can easily presume immunity from the ordinary rules of justice & decency. So many doctors are so busy in practice that they have very little time to ‘listen’ to a patient’s complaint ,no time to thorougly make a good physical examination , so a short cut is adapted . Only chief complaints are heard (not listened) & an array of investigations are written for the patient .So many want their pathologists & radiologists to give them a diagnosis . We were taught in the Medical collages to give prime importance to patient’s history , & good physical examination , corelating these to come to a provisional diagnosis & differential diagnosis. To confirm the diagnosis help of investigations is taken & a Final diagnosis is made , before starting the treatment. To follow 7 stages of ‘diagnostic crescendo’.
Tubular vision –every specialist seeing his or her system or part of the system , forgetting that human body is not a machine of assembled spare parts. Man is more than the sum total of his organs & parts.
Ivan Illich has already concluded Doctor’s effectiveness in patients’ cure as an illusion . But in all cases it’s not true. Efforts are needed to educate our population so that they can help in their own diagnosis , can know that only high technology & lot’s of money can not save them in critical problems . They must demand their diagnosis from their doctors, should ask questions to their physician & then only take treatment. This Medicine’s Forgotten Man should make his presence felt in every stage of his diagnosis & treatment .


Role of Communication in Empowering Women Theory, Practice & Myths

In Uncategorized on May 23, 2010 by sushrutayan

“Humanity will benefit if raising children becomes a deliberate and intentional activity rather than the side effect of a natural need.” Sigmund Freud.
The spectrum of disempowerment of a woman in India:
Ms. Sunita Williams has recently been to India, the only woman in the world who has been in Space for six months. A partly Indian woman! And in India we still need to talk, write, and do something about empowering women who are biologically stronger, can fight diseases better than men, have more endurance, more flexibility in adapting, more patience. Her only weakness seems to have allowed the society for ages to make her weaker, exploit her. Today she has lost her self confidence so much so that we call her second sex, to which she does not even object.

The enfeeblement conspiracy starts from the embryonic stage. See the statistics.
Today we have a male: female ratio, for 1000 males: 918 females at its best. In some states it is as low as 850. Natural ratio is 105 males: 100 females, which due to man’s interference [read Asian son preference] have come to 120 males, to 100 females. Female number varies from state to state & is lowest in Tamil Nadu, somewhat unexpected & Rajasthan, followed by Punjab, U.P. as expected, & it goes on. These indicators tell the girls that they are unwanted, that they should not be born. Worse the girls if born should die. So much so that Mr Manish Jha has produced and directed a movie ‘Matrubhoomi—A nation without Women’ depicting the tragedy of being the only woman in a village & her torturous sufferings in a man’s world. Due to skewed sex ratio, life can become harder for many girls and women outnumbered by males, as pressures to comply increase. About a month ago there was report from Gujrath where polygamy seems to have been voluntarily accepted in some small village. Skewing ratios will lead to a rise in sexual violence and trafficking of women.

Responsibility of rearing a girl-child rests especially on mothers, and this task is very difficult. When a girl is born, the reasons for the agony of the mother can be stated in the order of importance –
1. The mother is already demoralised since she will be blamed for begetting a girl, although biology says otherwise.
2. The mother thinks of all the physical and mental pain, the girl child has to suffer, like her for being a woman.
3. That she will have an inferior status in the society.
4. That her chances for studying would be much lower than her brothers.
5. If she does study it may not be what she likes but what her likely ‘average’ husband and in-laws may look for or tolerate.
6. She may not have any career at all.
7. If she has one, she may not be able to progress in her career.
8. The sword of a huge dowry hangs all the time.
9. The apprehension whether she will develop in a physically attractive one or at least good looking, to succeed in the market of marriage.
10. Worries about protecting her physically to maintain her virginity, in this dangerous masculine society.
11. The extreme shame associated with a possible pregnancy in her vulnerable premarital life. It is much less a concern if the son goes wayward.
12. She should be able to anticipate and rise to the expectations of her in laws, submissive, taking initiative or lead as required, never questioning her in-laws or husband.
13. Whether she would be able to earn money with dignity as required.
14. That she should be able to produce sons.
15. She should be the jack of all trades but may or need not become master of anything. This list can extend.

From disempowerment to empowerment; the male side of it:
We often happen to read some boards ‘Nari Sahayta Samitee , Stree Atyachar Nirmulan Kendra, Mahila Sahayak Kendra , ‘Matru Sewa Sangh’ and so on. These initiatives typically extend help after the woman has already suffered. It is a laudable effort since that need is also severe. But it is a better idea to do something to save her from all these excesses and help provided. Other such initiatives should be directed towards preventing the atrocities from happening. This will involve a change in the mindset of her post marital surroundings and strengthening her husband not to brook nonsense even if it is perpetrated by his own people. Such an effort will go to the root of overpowering gender bias.

The approach delineated above is more fundamentally directed at improving her lot but it is not empowerment of neither the woman nor the people around her. Hence we will not discuss it further. Suffice it to say that the rest of the article will look at the experiments I have carried out through Communication as the principle weapon with like minded persons in Nagpur, Coorg and Vidarbha that were directed at strengthening the woman to stand up and live with dignity and resist unjust actions, subjugation, gender discrimination, assault, abuse and inhuman demands she is subjected to. The shades that dominate different initiatives are varied but the end result they achieved was workable empowerment within possible limits. This article refers to the work we have done for last 15 years.

The background:
I have explicitly assumed that barring the large city or metropolitan career women or the page 3 instances of modern women with number of divorces, broken relations, attending late night parties that lead to wife swapping, the Indian woman to the largest extent is still disempowered, be it in the villages or the small to big varieties of urban life. Many believe that women are powerful, self reliant and capable of doing all the work and dominate males in the social environment, especially in North Eastern and many a tribal regions and fishermen communities. Part of this self reliance could be out of the fact that the males are pretty much useless, drink and do not work that brings the woman to the forefront. The Maternal lineage practiced by Kerala for long has given way to male dominance again. That the media by and large projected her as a sex object, the films, baring a few have done the same or the serials have portrayed her in unacceptable colours. Hence instead of dissecting the disempowerment or the degradation caused, I would like to give a narrative of the experiments I carried out, the theory behind it, the practices that led to success and the myths that I destroyed on the way to help women discover a new and strong identity for themselves, helping a large male population on the way.

My motivation
• Stems from the feeling that this situation must change.
• That a deliberately thought out, serious, urgent, collective and patient, multifaceted and comprehensive effort, leading to imparting the seed of empowerment in the woman herself and nurture it was possible.
• Given a new ideal, a new perspective, a new cause, a new “model” the women could be rejuvenated.
• Communication is the key.

Some of the first initiatives:
I worked in Coorg, a place far from everywhere, a hilly tribal area, where normal sustenance under the severe geographical conditions was a challenge. We faced severe dearth of (wo)manpower for ward assistants, labour room attendants, operating nursing assistants, laboratory workers, office help in the face of our rising and complex work loads. We created all this work force, year after year by systematically training the average farm and estate workers with little knowledge of English. Some of them had borne the bricks of the hospital the trust constructed. With newer skills they improved their earning potential, became much better supports for the welfare of their families. Many excelled in their roles, over their male counterparts, which, sometimes, became a matter of strain in their life. On women’s day and other occasions I used to conduct sit down discussions with them to later acquaint them of issues like gender inequality, of parenting, of developing a new self confident image of themselves, of solving their anxieties and empowering them to overcome their situation. This was one of the most outstanding initiatives of my work in Coorg appreciated by scores of project workers over years. This emboldened me to take several other initiatives when I returned to Nagpur after nearly ten years. It might be better to give a statistical summary of all other initiatives I undertook in the last 15 years in Nagpur, tagged with a concept note.

The scenario leading to action:
By 1993 I started working as a senior Consulting Surgeon in a tertiary care hospital. By then the TV channels and the Cinema had started becoming lewd, the beauty contest pageants had started making their appearances following the anointing Miss World and Universe to two Indian women, even in smaller and somewhat conservative cities like Nagpur. The ideas of beauty and behaviour had started changing; lipsticks and facials, even in girls coming from impoverished families, became a high priority at the cost of nutrition and academic expenses. Even at that time adolescence was being bombarded with terrible myths and dangerous messages, inducing them to go wayward. It is far worse now. Women coming with last stage of breast cancer, something seen and felt by the women as a growing menace every day, was more disturbing, because the reason substantially was in the male indifference for female health. On the other side I was facing a huge female and male clientele of various grades of illnesses who needed tons of education about the disease and its causes and effects. HIV AIDS had started threatening the population and an epidemic was feared.

With a few men and women friends of mine we decided to launch initiatives on
1. Women empowerment as a fundamental, overarching activity.
2. Issues related to the disgusting exposure of female body, making it a matter for sale and titillation
3. Adolescent education aimed at girls and boys of ninth and tenth standards in different schools,
4. Good Parenting,
5. Breast Cancer awareness programs

We decided to start a study group for women in Nagpur starting with a dozen women in the name of ‘Stree Asmita Jagaran Manch.’ Our theoretical position was that we need to make women aware about their strengths, weaknesses, and to help them to build self-respect to be able to stand up against atrocity.

We selected some key messages that will help her gain confidence and relieve her of the unnecessary guilty conscious she was harbouring.
1. That she is physically, mentally and biologically stronger and more powerful is a scientific fact.
2. The knowledge about who is responsible to beget daughters and sons. (Simplified information about X and Y chromosomes and how they form male and female foetuses, that the father is if at all responsible for begetting daughters has gone a long way. It has relieved the women of the guilt complexes [and even now if uninformed] in large numbers and subdued the arrogance of men and have silenced even in laws in scores. Even to date this effort remains a highly successful one.)
3. Positive thinking, building self image, through counselling and how it can be helpful for her progress.
4. The message that they could fight against wrong traditions & prove their worth by telling them stories and examples of women who accomplished it.
5. Knowledge of laws that empower and protect women. It has helped so many women to become bolder than before.
6. Inculcating good parenting, for the father as well as the mother as one to one.
7. Professional development making the best use of the given situations & existing opportunities.
8. That Gender relations are not static & can be changed.
9. Women need to master the art of balance. Life should be more than a balancing act.
10. Achieving androgynous personality may help them substantially to lead the family life better.
11. Empowering women through education & knowledge.

Through focussed discussions, by writing articles in local dailies on topics, focussing on these themes we did achieve a measure of success. In one of the advertised program we held on parenting we had 71 mothers and 9 fathers. No comments are necessary. These discussions gave rise to a few major issues we decided to take up.

Marital Issues, Individual roles and Fighting against gender bias:
Ideas about manhood are deeply ingrained in people’s minds. From an early age, boys may be socialized into gender roles designed to keep them in power and in control. Many grow up to believe that dominant behaviour towards girls and women is part of being a man, as we shall see later as well. Here the role of father in the marriage emphasized preferably in front of the spouses was very important. Emphasizing the need for transmission of this culture to their sons was necessary. Such fortunate situations however were rare. If the father is co-operative with mother, and treats both the son and daughter with equality, the son will imitate him when he marries, or when he becomes a father, he may treat his daughter with dignity & equality. By doing this, the adverse gender-based norms and practices can be gradually transformed through educational, social, legal and other processes to promote equality of girls and boys. Without such action, unequal gender relations and power imbalances are likely to persist throughout adult life. Women cannot achieve gender equality & sexual & reproductive health without the co-operation and participation of men. It is men who usually decide the number & variety of sexual relationships, timing & frequency of sexual activity & use of contraceptives, without asking the woman and before the problem arises. Women cannot achieve gender equality & sexual & reproductive health without the co-operation and participation of men. Pregnancy terminations or otherwise, and such other options are exercised by male prerogatives sometimes through coercion or violence.

The Program under the name and idea of premarital counselling was directed at the graduate and post graduate level of eligible males and females, married or desirous of it. The proceedings would start with a questionnaire of twenty clearly formulated questions about marriage and married life in a larger perspective. The major foci were on the type of expectations, on dowry, the lavishness of a marriage, the way marriages were arranged. We also explored their ideas of Honeymoon, live in relationships, DINK (double income no kids) couples, trial marriages, the necessity or otherwise of the institution of marriage and family, and many other issues to explore how much they understood or thought about various matters. The questionnaire is attached as Appendix —. Before beginning the program we tried to pick the cues from the answers to break the ice and get the discussion going. A woman lawyer, a doctor, a social worker were the main discussants to answer questions in the interactive program. The average attendance used to around 60 and at least 35 to 40 such programs lasting easily over three hours.

We tried to tackle some conceptual issues like the word ‘Kanyadaan’ in Hindu Marriages. We emphasized that it reduced the girl, a living being to an inanimate object of exchange. We appealed to married woman to avoid ‘Kanyadaan’ in their daughter’s wedding. This was a difficult task. When women accept many a traditions without thinking about it, they also don’t have or show the courage to oppose the norms. Women feel disturbed if this is pointed out to them.

Changing one’s surname after marriage was also considered acceptable for the sake of convenience; women have gone much beyond it by retaining both the surnames. On the other hand, universally, women did not like to lose the identity with which they grew up by changing their first name. Use of ‘Soubhagya’ markers was also discussed. Women are fond of them, they feel a sense of security, the society gives them dignity and respect.

The uncanny issue was even married women are victimised by men, raped, molested, regularly physically and mentally tortured by their husbands, beat their wives.
Women, even then wear Mangalsutra and bindi for a false sense of “soubhagya,” which is empty of content. I pointed out the disparity in thinking and behaviour but left it to them think over and decide.

By doing these programs, we could at least plant the seeds against the adverse gender-based norms and practices in the women who attended hoping that matters would gradually transform through these educational, social, legal and other processes. It served to tell the males what is considered appropriate behaviour. My out patient department work in Coorg and in Nagpur is replete with straightening out these tangled matters while also dealing with the issues of pregnancies out of wed lock.

Cultural Pollution and Blunted Sensitivities:
I delivered a series of lectures at numerous places in Nagpur as well as in other towns of Maharashtra. My children who were around 9 and 7 years then even said that the cultural pollution is now resulting in to a “Noise Pollution.” Several strands were woven in the series. I challenged the excessive and empty emphasis on the beautification of the body without any concern about an all encompassing development of the female gender. Beauty contests of little girls imitating the adult models, clad in skimpy outfits were opposed. That hyper-congratulation of external beauty should be cross-checked as a matter of principle, was emphasized. Is a beautiful body and a face, neither of which is her credit, nor an achievement by itself, a must for every woman? Is there anything existing like the inner, inborn beauty of a woman? I also challenged the role assigned to women in advertisements – the naked sex object. These lectures were publicised and the gatherings used to be large often approaching a thousand people at a time. This by Nagpur standards of lecture attendances was a record.

‘Doctor,Tell Me About Sex,’ A Program by IMA for laymen
This was an offshoot multi-disciplinary symposium where a dozen speakers drawn from different life fields were drawn. My speech on adolescents and the sex scenario was novel, never thought of by the laity as such and received accolades. For the first time we tried to dissect the various connotations of sex trying to emphasize that sex organs and the sexual act with its medical implications was not the only connotation. I defer from calling it ‘sex education’. This is actually family life education, inculcating the norms of behaviour and primary decency of inter-human relationships ,self control and deferring gratification and letting go personal needs . This was received well. One great learning was – two doctors outside the pale of speakers insisted on speaking. They delivered a message which was the irrational, lewd and uncivil, which surprised us and pained for the limited and somewhat perverted manner in which their ideas were presented.

TV and Ourselves:
I made an attempt at rationalizing the TV viewing, and a forceful attempt at imparting Education on the use of Media. How to watch Television, why watch it, what to watch on Television, and what not, how to overcome the addiction of excessive viewing, how to watch TV with children and family with elders, were some of the issues addressed. Excessive viewing is no longer confined to children but is a rising universal trait. I also focussed on the myriad disturbances excessive Television viewing led to; family strains and infighting, the phenomenon of couch potatoes when their children started emulating them. We did not know then but the couch potatoes have created a new breed of adolescent teen age diabetes of the adult variety leading to harmful physical and mental problems, deadly complications and truncated life. Lack of concentration in studies, attention deficit learning disorders became a focus then. Advertising Standards Council of India was introduced to the gathering. They were requested to make it a point to freely write to it as and when they watch faulty or unethical advertisements. I could not continue the series but this program drew one of the largest crowds for what seemed to be so mundane an issue.

Brest Cancer awareness programs:
This has remained one of the longest lasting programs. Breast cancer is a far commoner disease than many of us may think. It had two distinct scenarios. One was the sufferers coming from villages, from illiterate backgrounds. What stood out in these cases was the male indifference to what they see as a day to day growing menace they see. Receiving such women in late stages of disease and the subsequent suffering was no surprise. What was startling and frustrating was the callous, indifferent and unscientific attitude with which well educated people dealt with this surface malignancy of a dangerous nature. The latter in particular has led me to consistently conduct these advertised or community invited programs as far away as Bangalore. Breast Cancer Awareness programs are conducted at least once a year on 9th October the ‘International Breast Cancer Awareness Day.’ Other than awareness about breast cancer I teach them Breast Self Examination. It is conducted in the city as well as villages. Recently there has been an increasing demand to conduct them in smaller towns in Vidarbha and adjacent Madhya Pradesh. This certainly helps women to empower them about a very dangerous disease, and the knowledge that if detected in 1st stage they are and can be cured.

Followed by every well attended program I meet women in the same disastrous condition we were trying to prevent them from landing in, bringing me back to the reality of how inadequate the efforts were all over the country. In all these programs , in cities and in villages the peripheral, economically disadvantaged and such other communities also reach us.

Over time we decided to focus on the issues related to adolescent education of both girls and boys as the area that would probably yield maximum gain in the changing social milieu. My most voluminous work over the last 15 years has gone in this area and it may be good to report on it first.

Identity Crisis of adolescents leading to confusion over Dreams & Facts, became our guiding principle of this program. Someone has said, “if you don’t teach your children about sex, dogs will teach them.” I have a question about this saying: who has taught dogs about sex? But let me explicitly state, as I declared in each of these adolescent gatherings in schools that this was not about sex education. Most of the school authorities we talked to for conducting it conveniently narrowed it to this trite. It was a program about adolescent physiology, the ‘strum and dang’ the psychological turmoil of adolescents, the misconceptions they had about their bodies and the changes, and the incorrect attitudes they had towards their gender role and their perceptions about it.

Sex and the adolescents:
Sex is a natural instinct in every living being like hunger, and a need for reproduction for continuation of species. What is a natural instinct need not be taught. Perhaps the only education in a human being’s life that takes place by “default” in most cultures is the one about sexuality. This is an education from which parents shy away and the teachers conveniently ignore, since it does not feature in the curriculum. And thus unfortunately the main sources of this ‘knowledge’ in our culture are destined to be one’s friends, who could not be more knowledgeable, or sleazy magazines which come cheap and which propound a lot of unscientific matter, ridden with sexual misconceptions as “sexual knowledge.”

In late adolescence, the pressures to have a complete sexual experience become more intense. Sex is used as a popular topic in entertainment and to sell a universal range of products. Right from a scooter, bathing soap bar, tea, coffee, bed sheets, cars, undergarments, diamonds, lipsticks, to contraceptive pills and devices, and condoms, the range is infinite. If advertisers can somehow find a way to make a product sexy, or associate it with a sexual image, it stands a better chance of enticing consumer interest of which the adolescent is the most susceptible. Sexual content is standard fare in shows, in print and in songs. The media is filled with male and female sexual images illustrating or implying the power and pleasure of sexy appearance and sexual behaviour.

The scenario of the culture of sex then:
Given this constant commercial assault since early childhood, how could adolescents not be preoccupied with sex as they grow up? Even more influential than the sexual images presented are the sexual roles that impressionable adolescents are groomed to play. Believe the images, and you would think women are primarily supposed to be sexual attractors, trained to be preoccupied with their appearance to win male attention. Believe the images, and you would think men are primarily supposed to be sexual aggressors, coached to act manly to win female admiration. To see these images in action, just attend any high-school game where young girls in formfitting costumes cheer and dance, and young men bulk up in pads to show how hard they can play a sport. No wonder so many teenagers believe that emulating these images and acting out these roles are how they are meant to excite interest from the other sex.

We conducted some research to see what the ground reality was. The American Psychological association reported in 2002 that about half of all high-school students, when surveyed, admitted to having had sexual intercourse. We found several shocking surveys conducted in Indian Metropolis.

In one survey, 11th & 12th standard boys were asked some questions, one of which was – what do they feel is most enjoyable for a man? The answer was “Raping a woman.” When asked if they had experienced this, 2-3 % replied yes! About those who had not experienced it, were asked, why they said so? The only reply was, “We have been watching films often. The one who rapes is seen smiling & enjoying, and the woman cries and shouts. Thus we thought it is the best thing.” Such is the impact of the media!!!

Another important survey I happened to read then in November 1992 – 15 years back was reported in an article in “Indian Express” – ‘Increasing AIDS Menace in Schools’ in Madras, now Chennai – the most orthodox metropolis of India. The Story was – among the students of 10th & 11th standard they had detected many HIV positive cases, both boys and girls, in various schools. Some girls were pregnant and when they went to Gynaecologists for terminating their unwanted pregnancies, HIV was detected. Then a chain of positives was found in their partners. An urgent meeting was called. Principals of all the involved schools from the city met. They had long hours of discussions. Ultimately they came out with only one solution i.e. “We should start teaching these students about condoms.”! Sounding very simple, even rational; if you are going out in rains wear a raincoat & go! No hassles! This scene could as well be there in any other cities of India tomorrow.

A similar survey of Delhi male students, which said that to prove their potency before marriage, they visit prostitutes often, sometimes even force their friends into it! On the other hand we were somewhat vaguely aware of the high prevalence of paedophilia in some of the most backward provinces of the country. Worse was the routine use of the victim teenagers by predatory victorious elders that perpetuated the cycle when the victims later became aggressors.

Sex scandals from Jalgaon, Malegaon, Sawantwadi, Parbhani from Maharashtra also
came to light, during same period. Girls and boys watching blue films in small
groups was observed, followed by police enquiries etc. Excessive permissive
freedom from parents usually coupled with free money supply leading to
“adventurism” resulting in spread of AIDS, DRUGS, Human trafficking was rising
as was premarital conception and rising MTPs during that time.

66% of 15 to 19 age group in developing countries have had at least one sexual experience, (WHO 1992). Another story narrated to us by a parent: A cute little 5 years old sister affectionately kissed her 2 yrs old brother. Their 8 yrs old cousin who was playing with them yelled at her saying, “Tinku, don’t kiss him like that, you may give him that AIDS.”

Adolescents under the media assault:
Television now has a central position in the drawing room, and since cable networks started-off. No Censor board or political leaders feel the need to control or restrict obscene programs, scenes, 24 hours of a day. Video parlours, video tapes, cds, MMS’s, E-mails, Internet in plenty are available to anybody anytime, to use or misuse. What must be occurring while watching “soaking” ads of Sanitary napkins? Are we waiting for red appearing over it? What must be happening in the heads of toddlers while watching Condom Ads, ads for Choice tablets or Mala-D? Rape-scenes, gory murders are making kids insensitive to violence. Fashion channels, M-TV, Zoom TV, and Channel V are very popular among adolescents.

The roots of such an impact can be easily traced to the propaganda of HIV-AIDS that has been going on at feverish pitch. The messages given on Television, Newsprint reach everyone, children included. Many a times schoolchildren are asked to have a rally for spreading AIDS awareness, especially when 1st December is near. Are we really successful in achieving AIDS control by doing all this? Giving wrong messages at wrong time, how do we expect “innocence” to stay on this Earth? Those who really need this education are watching these Ads or not? Does anyone think about all this?

Blaming the television, Channels, Cinema, Magazines, blaming politicians, blaming society, or last but not the least, blaming men, is that enough? Is blaming somebody going to change these things? Are PILs and mass protests going to make a better society? Neil, an American scientist had said, “Indeed there are no problem children but only problem parents and a problem humanity.” Even then will this suffice was our concern. Those who are victimised in such a society finish their life 100%.
Risk taking behaviour and aggressive sexual behaviour on the part of young men are applauded by peers and condoned by the society. These stereotypes result in harm to both women and men and erode possibilities of establishing satisfying, mutually respectful relationships. Ideally, boys and young men discuss issues surrounding masculinity, relationships and sexuality. This can contribute to the deconstruction of negative, high-risk and sometimes harmful attitudes. That the rights of women are also as equally human rights is forgotten in these gatherings.

The Way Forward:
We cannot go back now. We had to decide on something new. Our conclusion was that there needs to be a strong counteroffensive directed at these sensitive adolescents. Their physical & mental vulnerability, emotional labiality, needs to be balanced against the excessive disinformation load and the freedom they take and the right message was required to be driven in.

We believed that this situation must change, stemming from the deep concern over the adolescent population, coming with a desire to help the girl victim in particular by imparting proper knowledge to girls & boys and eradicating misinformation and that it was possible to convince them that all dreams are not facts.

Scope and Focus
1. To help adolescents to view themselves as passengers in transit through a phase of development rather than as persons who have arrived at their destination and not wanting to go any further.
2. Prepare future adults by reducing adolescent confusion and developing them into individuals and not Carbon copies.
3. Reducing atrocities on girls & women. Instead of teaching only girls what to do and what not, telling boys – future Men – how they should behave so that girls will not feel the danger of the males in the society.
4. Our belief was that the 8th and the 9th standard boys and girls need this education most, to know how to do “The Right Thing at the Right Time,” when is the right time and why. That was the most appropriate time. We also discovered that even parents and teachers need to be told about these matters.

Relevance of this program prospectively and in retrospect:
a. It lies in the fact that a large percentage of parents are worried over the facts of the background stated. The parents themselves are not comfortable with their own sexuality. In a later program the University of Newcastle conducted in India for long years even the doctors were uncomfortable with it. The excessive preoccupation of the North with women and sex in particular even to date and the trade related to these issues that still flourishes strongly indicates the absence of the right input for the young men and women.
b. Experience we have by now gathered over around 300 + of such programs conducted over many years that parents do not know how to tackle this.
c. 50% of AIDS population is between 15 to 24 years of age. (WHO Global survey).

The Program and the developments leading to the pilot programs:
A series of ten intentionally interactive lectures for two good schools in Nagpur was our Pilot Project. The first school was B.V.M. School (Bhawans), children from the affluent communities came to. The second was Saraswati High School, a Zilla Parishad school with students coming from the average middle class or below. Both schools were supposedly the Indian Cultural Bastions. Both the schools were co-education schools as we wanted them to be because our focus was both the boys and girls should take part in the program together. Taking with us the teachers from The Department of Human Development, L.A.D. College we discussed with the Principals of both these schools in detail about our pilot project. Both of them were keen to conduct this program. We named the program as “Dreams and Facts.”

The Questionnaire:
On the first day we gave the students a questionnaire, to answer and examined the answers. We were interested in knowing their family background, healthy values, addictions and atmosphere; we also wanted to know about their basic knowledge and attitudes about the other sex, their ideas about cross gender friendships and fears if any and adolescent changes including menstruation. (This questionnaire can be found in the Appendices.)

We were surprised to read many answers and our thesis that these adolescent are very confused, had incorrect notions and they needed help was amply confirmed.
• Nearly 75% students spent 4 to 5 hours in front of Television daily, on Sundays 2 to 3 hours more. Purpose of viewing was in 90% for entertainment, for knowledge 10%.
• Boys take pride in teasing girls. They enjoy making fun of girls or troubling them. Boy considers it as his birthright.
• 90% boys consider girls as inferior creatures. 90% girls feel boys as their equals.
• Students having Quality extracurricular reading are only 2%.
• 70% to 75% students think they can make confident decisions about anything. They have inflated ego.
• In 30% homes, adults are addicted to something – tobacco, gutkha, smoking or drinks.
• Only 10% students exercise regularly.
• 20% students take balanced diet regularly.

The Lecture series:
Following 10 topics were covered in 7 days. Every day the last 2 periods were ours, totalling one hour and thirty minutes. Participatory lectures with discussions, charts, slides, films and booklets were used .The language of communication was mainly English, but certain explanations were also given in colloquial language. Question and answer sessions were always most interesting and revealing.
1. Teenage, puberty, adolescence-physical and mental changes, in girls and boys. Elaboration of hormones; causes of these changes; (common to both boys and girls).
2. Menstrual cycle and menstrual hygiene.
3. Manhood, nightfall, masturbation and STDs.
4. Daydreaming and danger-signals.
5. Love and friendships. True friends, depth of love.
6. Concept of beauty, need of beauty-parlours and fashions.
7. Right food for teenagers and importance of exercise, dangers of addictions.
8. Need for marriage, importance of the family-system and society.
9. Money, modernity, materialistic world and scientific outlook.
10. Importance of discipline, culture, ethics and mission in life.

We completed pilot programs very successfully. Students asked many a questions frankly. We could satisfy their curiosity. They were happy since their confusions were cleared. We evaluated our program on the basis of feedback we received in writing at the end of the program from 90% students. Almost everybody liked the program. Few girls came to us and cried. They were so depressed before that they wanted to commit suicide over their confusion and because no guidance was available. They were the most happy. A few notorious boys, already spoiled were sent to counsellor of the school.

Over a period of time as we gathered more experience we made these programs shorter hence more effective without affecting the contents. So far we have conducted these programs in 276 schools with an average attendance of 80 to 100 boys and girls since we do not take more than that for a session. Sometimes in smaller towns I have addressed gatherings of over 300 girls and boys for hours on end as the questions after the formal lectures and interactions were over, the exchange would just not stop. These programs still continue. Many a times I accidentally come across with some of these grown –up students. They still remember us, give us a lot of credit, keep on appreciating and accept need of such programs .We feel satisfied partially. Expansion of such programs is a need. Communication does help change people, change ideas and transform moths into butterflies.

The only thing I feel bad about is my failure to quantify the effects of this largely appreciated program. Lack of resources, manpower, availability of systematic researchers, funding has not allowed me to do it. So is the case with many of the initiatives that follow. Consoling myself with the general optimistic wisdom that such initiatives do change life I can not offer anything more to the reader.

What the Times of India editorial November 2007says –“Let’s Talk about Sex” is worth quoting. ‘Opposition to sex education is a case of misplaced morality. A nation with a population in excess of a billion is clearly not abstaining from sex. When it comes to sex, hypocrisy rules in India. The opposition to the introduction of sex education in schools – starting the current academic session – comes from several quarters, united by a misplaced notion of morality.
‘The argument that talking about sex is antithetical to Indian tradition is nonsense. A revision of our outlook is long overdue. HIV/AIDS and other sexually transmitted diseases and unwanted pregnancies are on the rise, largely due to unsafe sexual behaviour. It is an inescapable fact of our times that Indian youth are becoming sexually aware and active at a much younger age than before. It is imperative that they are equipped to take responsibility for their reproductive health. To that end sex education, shorn of morality and informed by fact, must be easily accessible in schools. The longer we hang on to our outdated attitude towards sex, the dearer the price we pay for coming generations.’ Even after 15 years, state after state, people with different and fighting ideologies are still united over something which is completely obsolete.

Workshop on Censor Board:
We conducted this more for the enlightenment of our core group with the help of a well-known woman lawyer, an advertising agency man and one of the members of the censor board. Hundreds of people attended that. We learnt that in the Censor Board meetings neither is the quorum complete for the grading anything that comes through audio visual medium, nor is enough care taken to ensure that right things are shown to the right people at the right times as well as many other dysfunctional elements in it.

The Most Novel Campaign of Ours:
This was about the disposal of sanitary napkins properly. Information was circulated in the form of thousands of pamphlets in Marathi & Hindi, (to be found in the Appendices.) The response was astounding. The pamphlets were then sent to all women groups, schools, colleges and hostels. As and when our members visited any women group, they would distribute pamphlets. The pamphlet also appealed to them to copy and to circulate it to as many girls & women as possible, not to keep it with themselves, not to be torn, so that the message spreads across a larger section. The city’s garbage dumps showing bloodstained used Sanitary Napkins here and there seemed to have decreased.

This is a brief review of unhealthy practices we went after and ideas we experimented with. Let me be candid. Many of them could not be converted in consistent activism. But this account will serve to illustrate how they were practically developed to become useful for someone else who might have the wherewithal for them.

How does all this empower women?
Obviously all the initiatives are not capable of translating them in a movement. Many of them are matters for general enlightenment for those who deal with women problems of diverse nature. Whatever the initiative, what strikes the woman’s mind is that there is somebody, you don’t even know, feels passionately for you. This experience is not common to women. To understand what this facilitator is saying, is the most important. To form an acceptance or rejection is a much later stage. Less endowed women somewhere slowly realize that these were her unknown fears, concerns, matters she wanted to get clarified about, the desire of knowing. Even the less endowed women slowly realize that these are the ideas which have resonated somewhere so deeply in her conscience that she had not even been able to listen to them. They also realize that there is something about her self image, her proper station in life, her rights, the discrimination and subjugation she has undergone, the unequal value of her contribution that has been thrust upon her as her fait accompli that she is being made aware of and she would like to see this given to her as her just due. All of these aspirations are awakened and get fulfilled. The empathy emboldens her to a dialogue. There is a support for her to look at herself as an independent entity with self respect. The lives were dark and constrained, not always aware of all the deprivation. Even a ray of light is sufficient for a substantial realization of what is possible, to arouse her inherent strength and facing challenge. Some may take it up early; some will take it later with caution, depending upon the hundred different backgrounds of hundred shades.

What else is empowerment? There may be an initial trepidation of what she has learnt and what may happen when she confronts her counterpart with it? That is transitional.

The author firmly believes that even complex science is not beyond the grasp of the most illiterate women, many of whom have an understanding the ‘soil’ gives them.
Empathetic, emboldening communication is the key. It certainly makes changes in thinking, reasoning, and gradually the woman starts putting herself together. These changes may be slow but they are inevitable. The quantum population change will depend upon the number of initiatives address women.

The array of ideas and models tried out, detailed hereinabove, is with the same hope of Bhavabhooti – The earth is vast, the time is infinite but I must wait till I am joined by someone who is like me, my samanadharma, who will also take it up.

It is certainly better late than never!!