India raped

On the threshold of 2013, a nation in its 66th year of existence as an independent state, India has to surely hang its head in shame in the pantheon of civilised democracies.

The expected happened. Precisely why she was moved to Singapore. You wanted to shift the focus of an uprising within the country and smoke it out. Objective achieved. Give yourself a pat on the back, clever politicians of India. The criminals in this entirely sad but telling tale are not the rapists, but the people who have allowed it to happen. A nation with a constitution but no will to question it, a country with a vast police force and extensive laws but without the will or courage to enforce the rule of it. We elect governments, we represent the country, we the individual citizens represent our culture. Therefore, we cannot blame just the government and the police alone. We are equally responsible for the decadence in our attitudes. 

I do not want Nirbhaya to rest in peace. I want her to haunt every single man who considers women as implements of sex and free labour. 

Believe me, Nirbhaya's death, and not the several multi-crore scams of the past few years, defines our country. Defines it in such a way that we cannot go out and cry to the outside world that we are Indians. A nation steeped in such chauvinism and misogynist depredation that the first family' son labels, with no compunction (see his response to Arnab's badgering - on YouTube), women protesters as 'dented and painted'. And, the top gun of the ruling party was mired in a gang rape case. The list of politicians charge sheeted with rape is endless. Several regional politicians advise women not to wear 'non-Indian' clothes and avoid going out 'unaccompanied' at night. Women going to 'clubs' are immoral, but men doing the same are just letting their hair down, no harm done.

All of which reflect this simple fact - this 'culturally rich' country systematically engenders male chauvinism. Fuelled by idiots of both sexes. In fact, the females of this society are as much, if not more, to blame as the vile males for this cultural deprivation - exemplified by domestic abuse of women by their mothers-in-law, for failing to bring enough dowry, for not slaving enough at the coal face, for not bringing up the children right, for dressing up, for wearing make-up, for chatting with male neighbours, for going to the movies, for having fun, for just living. 

We are a nation of hypocrites. The men want other women to be promiscuous, but want their girlfriends and wives to be faithful. They want their sisters to have arranged marriages, but want to marry the ones they love. The husbands want to be like bachelors after marriage / children - they need stress relief in the form of alcohol and gambling, but the wives have to toil taking care of family / children and this misogynist chauvinist of a husband as well. The men will wear kumkum on their forehead and pray to several female gods - Lakshmi, Saraswathi, Durga et al but will loot, rape and cheat with no fear; in fact, several, fuelled by the 'powers' vested to them by such gods, do worse. The list of hypocritical views of men in this country is endless. Worse, this is systematised. Just like caste and religion, it is congenitally transmitted. Until this, the root cause, changes, women will not be looked upon as human beings born equal in every way to men.

Shoba De in her recent piece in ToI said it well (http://blogs.timesofindia.indiatimes.com/politically-incorrect/entry/girls-don-t-run-scared-anymore). For women living in any modern democracy it should not be a question of restrictions and living defensively, but about the ability to move about just like any male in the society. It is a constitutional right. The onus of an individual's safety is not upon us but the guarantors of the constitution - our elected lot. When they rape, loot, scam and abuse power with no impunity, then we are not a nation at all. India has already proved itself to be a failed state - we, the citizens, are too apathetic to have noticed this. Such is the misery of daily life for the aam admi. 

Rape, in its original definition meant - to seize, take or carry off by force. And later, the connotations of violent plunder and abuse have come to the fore. In this latter sense, rape can also be used to denote the systematic abuse of an object or person. Thus, whenever we abuse a person - child labour, slave labour, forced sex on any human being - we are effectively 'raping'. Hence, any change to the status quo must start from within us as individuals. We need to change our attitudes, as individulas. 

On a mundane level though, the immediate need of the hour is for the government to act swiftly to demonstrate that it means business. Eradicating corruption, enforcing the rule of law, vigilance against all forms of male fide intent, protecting citizens just like it protects the netas would be a start. When even a simple Lok Pal Bill cannot be passed in parliament, can we expect any of this from the elected lot of this country?

India, when you have been raped irreparably by our politicians repeatedly, how are we going to defend the rapes of its citizens. Is there any hope? I know not. Rise, India. Before it is too late. Before anarchy pervades.

Satyameva Jayatae!

Truth alone triumphs.....stuff that is seen on our national emblems everywhere. From the humble rupee coin on. But, as one English barrister pointed out to the presiding judge, truth is a matter of opinion. And, in India, truth has many facets. The truth of the netas, the truth peddled by the babus, the truth of the aam log and so forth. It is one of these 'truths' that Amir Khan took on recently.

First off, kudos to Amir Khan for 'exposing' medical malpractice and related issues on a national TV program. My respect for him went up a notch when he did not back down or apologise when threatened by certain medical bodies.It is common knowledge about kickbacks, that start from referral of patients to other doctors or hospitals / nursing homes to getting a 'cover' back for sending patients for CT/MRI/ultrasound scans to getting bribed for ordering a long list of unwanted investigations. It is also true that many smaller labs end up doing 'sink' or 'basin' tests where, if the patient is 'normal', unnecessary investigations are ordered by the doctor but does not get carried out by the lab, with the samples being thrown into the sink/basin.

How did this come about?

To me, with my plain simplistic view of life, the answer is simple - AVARICE.

This may appear too simplistic an answer. But scratch a little and we can unravel a few strands that go into the heart of what makes this nation as it stands today - chaotic to the point of anarchy, total lack of morals and ethics, progress at any cost without conisderation of human, environmental or future costs, lack of the three C's of social cohabitation - common sense, civic sense and civility.

What has pushed this nation to this level? Is it due to the repeated betrayal of trust placed by a nation on it's governing members? Or is it mere selfishness? I guess the answer lies somewhere in between. Naivete / ignorance of the people,  an excuse often offered to me by some of my friends does not hold water. Recent elections in TN, UP and Bihar prove that.


Would I be right in thinking that this country's aam log have never been or inadequately educated on civic responsibilities and behaviour? This combined with lack of, rule of law, and enforcement has led to where we are today. 


My observations point to this - parents do not educate their children right from a young age about what is 'right'. When they go to any place where queuing would be the norm, whether it be a cinema hall or a sweet shop or an airport ticket counter, the adults just go to the front of the counter expecting to be served before somebody who has been waiting patiently for a while before them. The child observes this, and this wonderful social behaviour has been 'passed' on down generations until this has become the 'norm'.


This behaviour translates on to the road as well - I do not give a monkey's toss about others waiting in the left side of the road, I will use the right (opposite) side of the road to overtake every single vehicle waiting in line and get to the front of the queue, even if it means blocking the entire traffic on the opposite side of the road for hours. So everybody does the same, irrespective of their educational or social status. There is a phenomenon observed in birds and monkeys called mirroring. Indians exhibit the same phenomenon everywhere. A violation is considered a violation only if one or two people do it. If everybody does the same it becomes the rule; the person waiting in the queue is an exception and is a fool indeed. 


I digress.


Returning to the issue of unethical practice in medicine, I feel it is avarice that has taken the country spiralling down the dark path of degeneration. This, in a country that for eons has espoused quite religiously the tenets of contentment and satisfaction with one's available wealth and abhorrence of avarice. Lord Krishna resides by the bedside of fools, indeed, who feel their actions in all spheres of life are blessed. Like Kamalahaasan's Naicker delivers the classic and unforgettable line in the movie Nayagan, "Avangala nirutha sollu, naan nirutharaen (Ask them to stop, and I will stop)" - Indians expect the others to stop doing all the nasty stuff before they will shun it!


Is there any redemption for this nation? Unless there is a large scale revolution in social education and responsibility, I do not see anything significant happening. Mere enacting of laws that curb unethical practice, unless accompanied by powerful jaws of enforcement, will do little.Just like the red light is flouted in every traffic junction in this country...


At the end of the day, every citizen will have to realise that they are actually responsible as individuals for the downward spiral this nation is facing. Pritish Nandy has written a good piece about Aamir's show (http://blogs.timesofindia.indiatimes.com/extraordinaryissue/entry/does-satyamev-jayate-work). I think leaving aside all the other stuff it is important for us to dwell on the last paragraph of this write up. Somebody is telling that the emperor has no clothes. 


Aamir Khan is an intelligent person. He is not an intellectual. He's just using his star status to make certain social observations. Such social commentators need not necessarily be social engineers. It is not Aamir's job to correct the ills of society. More than a billion people have vested that responsibility on their elected government. Now it is up to the emperor and his ministers to do something about it. Will they?

How Goliaths are killing the Davids!

Dr David is a NRI doctor who completed his higher surgical training a few years ago in the UK. He then worked as a consultant orthopaedic surgeon in a large district general hospital in the south of England. He is married, with a wife who works in the IT sector and two kids - a girl, 14 and a boy, 10. He had some compelling reasons to return to India, most of them personal. But, he also harboured a desire to improve the quality of care and increase patient information /awareness. He did his homework prior to relocation, and targeted a few large corporate hospitals - Goliath-1, Goliath-2 and Goliath-3 were the most popular in the city. The reason for choosing to join a corporate hospital was that he was offered a reasonable retainer; something that will keep him & his family comfortably fed, clothed and the children schooled whilst he established his reputation and practice. Despite a lower salary, he chose Goliath-3 as he felt that it had the best infrastructure, a good set of colleagues in other departments as well as his own.

Dr David started getting disillusioned after a few months. He had been promised incentives - a percentage of earnings / revenue generated above his retainer level - after a 6 month period, depending on his turnover of patients and in turn, revenue. Within 4 months he had broken the retainer barrier and was generating sheer earnings in terms of surgeon's fees of at least twice that of what was being paid (as retainer). He discussed this a few times with management, who kind of promised him that it will be reviewed soon. 

Almost 18 months had passed when Dr David started realising that he was being taken for a solid ride. He started looking at options in Goliath-1 and Goliath-2 - the two other major players in the city. 

Goliath-1 was a well established brand that was notorious for it's unethical (mal)practices. Although, the revenue generated would be very good, Dr David was not comfortable with their practices; plus, the operating theatre availability was limited and there was a lot of internal politics. He didn't want to get mired in this. 

Goliath-3 was better in the latter aspects, but was run by a neurotic/psychotic. Dr David, again felt uncomfortable even thinking about moving there. There were, of course, certain other 2nd level corporate houses that did not have this retainer culture, but he found out that they lacked culture, period! Also, they did not have any of the equipments / instruments required for the kind of specialised work that he did; other consultants were bringing in their own instruments to work and were charging the hospital for it.

So, nearly two years following his relocation to India, Dr David was at a crossroad - he could either swallow things and maintain status quo, or start visiting several hospitals and collect a fee for service, or build / establish his own nursing home / hospital. With the fee for service model, he found that most hospitals levy a 15-20% service charge on the surgeon's fee (in addition to the tax deducted at source). Dr David was beginning to feel a sense of strangulation - the Goliaths had perfected the art of strangulation whilst he had been away from the country. It was their way or the highway.

Dr David is now seriously contemplating returning to the UK. He has looked at other options like the Middle East, Australia and New Zealand.

Dr David's case is just one example of many well trained NRI doctors who return to India with visions of making things better only to be completely disillusioned. Losing one's vision is easy if one is not lion hearted and perseverant. 

In recent years the government has  relaxed a few regulations to encourage more NRI doctors to return but clearly this has been a half-hearted stab - most NRI doctors tend to specialise in their respective fields, whereas the current regulations do not allow accreditation of the specialist qualifications (for example, whilst FRCS is recognised as a 'higher' qualification, FRCS (Urol) is not!!). My take on this is that this was probably done to protect the turf of the 'locals'. I mean, who is the loser? The poor Indian patient, of course.

There are several doctors who have trained exclusively in India doing a fantastic job - be it the quality of their service, their communication skills or maintenance of ethics. I do not say this in a patronising or condescending fashion; because, there are quite a few who practise medicine in the worst possible way - full of avarice, unethical, uncaring and extremely condescending to their patients.

The combination of economical disillusionment, lack of public infrastructure, power outages, lack of common courtesy and civility, the need to 'put up' with unethical practices (since this is almost systematised, just like corruption) is enough to make someone who is used to a different way of life to pack their bags and head back to sanity.

The hangers on are brave indeed!

First robot assisted cystectomy in TN - 18 Jan 2012

Wishing one & all a very Happy New Year!

New Year = new tidings. I am hoping this will be the year that will serve to influence my continued stay in India!!

Another memorable day in my life: 18th January 2012.

The day I performed robotic radical cystectomy in Apollo Hospital, Chennai. This is a first for Apollo Hospital, Chennai, as well as for Tamilnadu.

KS at console of Da Vinci Si - Apollo Hospital

Radical cystectomy - this term refers to complete removal of the urinary bladder for invasive cancer of the bladder. The patient was in her early 40s and an inveterate smoker. It was quite unfortunate that she presented with severe urinary symptoms as well as significant loss of weight over the preceding several months. Initial resection of the tumour (TURBT - transurethral resection of bladder tumour) had revealed a high grade cancer invading the muscle coat of the bladder. Clinically, it was also stuck to the adjacent structure. Staging investigations had shown some enlarged lymph nodes in the pelvis, but no evidence of spread to other organs.

Under these circumstances, suitable patients are usually advised radical cystectomy and given a few options about how the urine is diverted - either into a loop of bowel that is brought out through the abdominal wall (ileal conduit), creation of a new bladder (neo-bladder) using small bowel, which is then connected to the native water passage (urethra) or into the terminal part of the large bowel (where it admixes with stools). These options vary between individuals depending on their age, performance status, co-existing illnesses / health problems, nature / extent of the cancer, etc. This patient was advised an ileal conduit.

Ports placed prior to docking of the robot

Radical cystectomy can be done in one of three ways - open, laparoscopic or robot assisted laparoscopic cystectomy. I have described the difference between laparoscopic and robotic surgery in an earlier post about robotic prostatectomy (http://krish-sairam.blogspot.com/2011/11/my-first-robotic-radical-prostatectomy.html). Having done all three forms of radical cystectomy, it is my personal opinion that robotic cystectomy offers advantages for the patient as well as the surgeon.

Robot docked to the patient

Advantages for the patientThe entire procedure including the construction of the ileal conduit can be done through keyholes (although in this particular patient we did the reconstruction through a mere 5 cm cut in the tummy). Since there is no large cut in the patient's abdomen, recovery is faster. Also, with the precision and  magnified 3-D vision available with the Da Vinci Si system, dissection is precise that results in very little blood loss if any. With appropriate placement of the ports, removal of lymph nodes from the pelvis (which is an integral part of this procedure) as well is done with ease.

Also, since the bowel is not handled much (as in open surgery), it resumes activity over a shorter period of time.

Advantages for the surgeon

Surgeon fatigue is reduced, which translates to better technical execution. The patient is likely to benefit from this. The views of the pelvis obtained in robotic surgery is unmatched - this is my personal experience. Since there is no chopstick effect (as in laparoscopic surgery), dissection proceeds with precision, due mainly to motion scaling and tremor elimination - this, in my opinion, translates to enhanced patient safety and reduced liability for the surgeon.

Note the steep head down position of the patient

Estimated blood loss during the procedure was less than 100 ml. Patient was ambulant in 36 hours and had return of bowel activity in just over 48 hours. She was discharged on the 5th post-op day (which would be an unusual occurrence with open cystectomy).

With TG

As procedures go in urology, radical cystectomy is one of the most morbid and complex ones, and doing it especially with robotic assistance requires patience, dedication, and an excellent team of table side surgeons, anaesthetists and nurses. I am very lucky to have Dr Thirumalai Ganesan as my urology partner. As ever, thanks TG for everything! At the north end of the table, I am most grateful to the couple  - Dr Sumathi and Dr Aravind. And my thanks to the nursing and support staff in Apollo Hospital, Chennai for making this possible. I am certain that we are in for some exciting times ahead!

May I take this opportunity to mention that my personal website is now online although the patient info page is still not complete. Hope you will visit the site (http://www.krishsairam.com)

and send me your comments!

And folks, remember - SMOKING KILLS. So please give up the vile habit.