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Chronic Kidney Disease and the Broad Street Pump

The bulletin of the Sri Lanka Medical Association (‘SLMA News’) of August 2012 (Volume 05, Issue 08, p 5) provides excerpts of a WHO report on Chronic Kidney Disease of ‘unknown’ aetiology (CKDu). The mission report it quotes, submitted in June 2011, called for the development of a regulatory framework to improve quality control of imported fertilizer – particularly with regard to arsenic and cadmium. The next report, of October 2011, says that it is imperative to have steps taken as soon as possible. A progress report in Feb 2012 again calls for implementation of previous recommendations and reiterates the need to strengthen evaluation and control of pesticides and fertilizer. It also recommends strengthening of water purification schemes and increasing awareness of renal toxicity of the herb Aristolochia.

We learnt in medical school how the enterprising removal of the handle of the ‘Broad Street Pump’ stopped a cholera epidemic in its tracks, well before conclusive proof was available to justify the act. But we cannot nowadays take the tiniest precautionary action – whether regarding agrochemicals, tobacco use,  the constant glorification of violence and suicide in the media, alcohol related harm, children (and adults) spending virtually their entire life staring at screens or economic policies known to increase mortality – that any powerful company does not like. Sensible suggestions are subject to unending debate, while thousands more victims are afflicted. We are now paralyzed – and many of us celebrate our paralysis as progress.

 

Precautionary action on the most likely cause

Why may we not address the fertilizer and agrochemical issues at least in one geographical area, say the worst affected, to see what may happen? Had we taken some small scale experimental steps in time, we’d already be underway to monitoring possible early outcomes. Why may not a principle of sensible precaution (see http://www.sehn.org/wing.html for an update) be invoked? I know that it is difficult to argue for precautionary public health measures nowadays. The tobacco trade led the way in ensuring that, in policymaking, precaution applies first to company profits. We have today a clutch of influential, and strategically placed, politicians (of all hues) and bureaucrats who reflexly oppose any measures that giant commercial agencies don’t like.

It is no surprise that there is no hue and cry in the private media (that go to town on far less damaging matters) or in the state media that urgent preventive action is needed. Calls to move away from chemical fertilizer and pesticides or for stringent standards to be applied are not among the ‘burning issues’ of the media agenda – probably for want of adequate inducement. There could, of course, be plenty of inducements not to fuss about these potentially harmful chemicals.

It should still be possible to launch trial preventive initiatives through the health sector. The giant agro-chemical players probably do not have well-placed friends yet, among health sector personnel – as the alcohol and tobacco trades likely do. (We need to study carefully the words and actions of key decision makers, rather than mere propaganda floated by their enemies, to decide if there are agents already recruited.)  If we suspect there are, we can collectively figure out ways to counteract their influence.  Awareness that others are critically observing their actions is also a deterrent.

 

Addressing other identified suspects

A second presumed risk factor that the report identifies – hardness of water – must similarly be addressed now. The cost of an initiative to provide softer water for consumption, to selected high-risk localities at least, and assess outcomes – up to 10 years, say – is still a miniscule expenditure compared to the cost of treating people after they develop chronic renal failure. This measure is much more feasible too as vested interests are unlikely to obstruct: there are no mega corporations making much money importing hard water.

If there were a mega industry involved, we’d have to apply principles relevant to dealing with industrial vectors (BMJ 2012;345:e5124) – which means that medical people have to acquire new capabilities. I worry that the public health community is not vigorous enough in advancing on this front. This is now the frontline in dealing with major killers. We must learn how to counteract any inhuman actions that we can spot, of human and corporate vectors. One of their actions is to covertly undermine, from within, even our smallest efforts. 

A further presumed risk factor identified in the WHO document is the ayurvedic medicinal plant Aristolochia. Once more, there is no need to wait for confirmation if there is fair evidence that it could be a risk. The approach should be to minimize exposure to it until it is found to be safe.  I presume that the Health Ministry and other concerned agencies and individuals are taking action in this regard, unnoticed. I add my own small effort to supplement these by making ayurvedic practitioners aware as and when opportunities arise. (A colleague kindly found for me the Sinhala name for Aristolochia – ‘sapsanda’. But I have not got the Tamil name yet. Nor have I succeeded so far in getting a sketch of the plant, to help people identify it. Maybe someone will feel the urge to do this.)

 

Looking further afield

Whatever success we may achieve, with vigorous campaigning, on the fronts pointed out by the WHO report, we shall never be allowed to address (or even mention) the other likely risk factor, active and passive exposure to tobacco smoke.

1. We know that tobacco is reported to cause chronic kidney disease: http://www.biomedcentral.com/1471-2458/10/731,

http://ndt.oxfordjournals.org/content/15/10/1509.full,

http://www.medicalnewstoday.com/releases/61882.php

http://www.ajph.org/cgi/content/abstract/AJPH.2007.130963v1,  

http://www.the-aps.org/,

http://jasn.asnjournals.org/content/15/8/2178.full

2.  We are told in the WHO report that the majority of CKDu sufferers in Sri Lanka are men over 40. We know also that smoking (as well as licit and illicit alcohol use) is vastly more prevalent in men than women in this country. And nearly all of them, an informant tells me, are smokers.

3.  I am not able to study the percentage of women CKDu sufferers who have been significantly exposed to tobacco smoke. But to do the study will cost very little.

4.  We know that various chemicals are added to tobacco in the process of preservation and making tobacco leaf ‘smokeable’. Full disclosure is not a strong trait of the tobacco industry, so some serious research will be needed to find out all the chemicals added to preserve, cure, prevent fungal and other growths, ‘enhance’ various biological effects and the like. The tobacco trade does indeed take its customers for suckers. Quite appropriately too.

Mention tobacco as a risk factor and a segment of any audience immediately switches off. This is the group of sophisticates who dismiss any evidence about the risks of tobacco as the inventions of anti-tobacco fanatics. Most of this class aren’t suckers of the previous kind either – namely, they don’t even smoke any more. But they are posh enough to know it is not at all trendy to express concern about tobacco (or alcohol) related harm. Say anything ever so slightly critical of tobacco merchants and those who matter quietly classify you as an outsider. Anyone aspiring to membership of ‘high society’ had better not look too hard at tobacco as a contributor to the cumulative risk for CKDu.  Many influential people ensure, for reasons unclear to me, that critical comment about tobacco is taken as a sign of belonging to the lower classes.  (Alcohol too has its defenders but they restrict themselves to licit brews.)

How long should we wait before warning people that tobacco is probably among the major risk factors, or before we study active and passive exposure to tobacco smoke among those affected by CKDu? Should we not urgently check what percentage smoked cigarettes, cigars or beedi, chewed tobacco, took cannabis, drank illicit and licit alcohol? Can’t assays be done to verify whether some of the suspect metals and organic molecules are present in significant amounts in the ‘safe’ (= produced by large corporations) and ‘unsafe’ (= made by small scale producers and often illicit) brands of these substances? Once again I try to do my own research within the limitations imposed by the time and other resources available to me. And I do what I can, to warn people. My efforts aren’t enough to make a noticeable dent but that does not stop me.

In the meantime I see no action – apart from miniscule individual efforts – on the other suspected contributor, Aristolochia or ‘sapsanda’.

 

Conclusion

The multiple underlying contributors to CKDu aren’t as easily dealt with as was the Broad Street Pump, especially as these are likely connected to powerful trades. In such cases, the option of applying simple direct obvious precautionary remedies is a non-starter – whatever the extent of death, disease and suffering potentially so prevented. The powerful pump owners have well-placed apologists and defenders to protect them from any threats to profits. They range from high profile politicians to inconspicuous professionals and administrators in key settings.

Despite all these obstacles, there is every likelihood that we shall dispel the new danger, CKDu. This country has been good at countering the varied enemies of the public good – ranging from the readily recognizable to the completely concealed.

 

Attractive bodies

 

                                      

 

 

 

 

 

Some body shapes are gorgeously attractive while others fail to arouse at all.  Beautiful bodies announce, ‘Hey, come to me. I can give loads of pleasure’.  As a result, consumers of sex selectively choose nice bodies to experience and enjoy. And people eager to make their body sexier readily pay for things that claim to make the body beautiful.

Had the promise of great sex not been inherent, we could conveniently have stopped at only feasting our eyes on shapely structures. But visually attractive bodies are preferred for sexual activity too. The beautiful body is rather like an advertisement that promises good sex. We know that advertising messages are not often true but we still let them guide our shopping. Is the ‘good sex assured’ message associated with nice figure a misleading advertisement? Or is it factually correct, just as some rare commercial advertisements too are?

The nice body openly promises to deliver pleasure. When it fails to live up to the promise, the reason is mostly that the actual sexual action has been poor or unskilled.  Another is that the individual concerned is easy to dislike. But doesn’t the sexually attractive torso override these and make the sexual experience great? It may do – but there are some obstacles to translating visual attraction into sexual enjoyment.

            A shapely body is best shown off standing. Take two bodies, one amazingly attractive and the other quite ordinary, and keep them side by side – standing and then lying down. The difference is generally more striking vertical.

            Next, look at the same body (whether horizontal and vertical) from a few feet away and then from within millimetres. As we get really close, the overall difference in form becomes less noticeable.

            Proper sexual activity usually requires getting pretty close and it is most of the time undertaken approximately horizontal. Both of these conditions render the attractiveness of contours less obvious.

            Where sex is undertaken in the dark, as it too often is, visual stimulus is further weakened. Fine bodies have a hard time making their visual appeal count during sex. (Pleasing faces too lose visual power during real carnal activity, but probably to a lesser extent.)

Is figure and form an overrated element in pleasure from sex? Or do size, weight, hardness and softness have a great deal to do with physical enjoyment? Does shape matter mostly because it tells us in advance about these other attributes? Are these questions unworthy of attention, given that we will anyway end up dead whether we have good sex or not? Can such questions have answers that apply beyond individual taste?

 

 

 

 

 

We’d be disappointed if we sought clues from scientific studies. There isn’t any convincing evidence accessible. Now is the time to do our own studies. Is fat a factor for us? Or only when above or below a given limit? How much does the amount of muscle affect pleasure? Is a given amount of fat or muscle less or more enjoyable depending on whether it is on a woman or a man? If so, why on earth is that? Does skin colour have absolutely no effect on pleasure, even in well-lit surroundings?

Looks are far more likely to be of consequence when sexual activity takes place with others connected only through electronic gadgetry. Physical form is easily seen and displayed when erotic communication is through web-cams, unlike when participants are up so close that only a few square inches of skin is visible at any one time.

Visual stimulus has the added problem that eyes may not even be open at times of exchanging intense physical stimuli. No such shutting of eyes is likely with  stimulation delivered through the internet. In fact eyes are the primary channel to gather internet-based incentives.  We can predict that body shape will become even more the focus, as nice clean internet sex replaces the unsanitary type that requires real physical contact with others.

Sexual pleasure is a major contributor to wellbeing.  It therefore makes sense to improve the pleasure derived from this source. Re-examining the contributors to those really good sexual times or events is likely to be beneficial. It should help us experience more such high points of pleasure and at least occasionally to beat our previous records in ‘great sex’.

 

 

 

 

Black and White People

 

Some 30-odd protesting miners were recently shot dead by police in South Africa, and hundreds arrested. Needless to say, they were ‘black’. The shooters were probably black and white. In the days of apartheid (or white rule over ‘colour’) the arrested miners would next be charged with murdering their colleagues – who were shot by the police. The survivors would clearly be seen as guilty of provoking upholders of the law. (The dead too did provoke, but even the long arm of the law has its limitations.) Never mind that the bullets came from police guns. This logic held sway for the police was run those days by ‘whites’, as were the mines, and the expat owners were also almost all white. Protesting miners were conveniently black.

Things have changed now. ‘Blacks’ can vote and so may ‘the brown’. The President is black as is the PM. Botha is gone but whites are still happy. Mandela the statesman helped them feel secure. Whites and blacks are now cleansed, of equally-apportioned sin. Together they grow and build the future.  It’s no wonder we are asked to copy this marvel of reconciliation and, of course, truth. No more can nasty whites shoot enslaved blacks at will.

So what happened after the recent police shooting? Surprise! The authorities filed murder charges against protesters who failed to die of police bullets (or avoid arrest). Just like good old apartheid days? Convenient old laws have not been repealed nor, it appears, the enforcement apparatus weakened. The resident whites (a diaspora?) must be made to feel secure i.e., their profits shall always rise, no matter what. If not, they may take their money and go. (Further west?) The economic order will collapse and the people who matter, of whatever skin colour, will make money less fast.

 

The black President says the charges must stand. Mandela will feel proud of new statesman Zuma.

And Tutu will deftly deal with this dilemma. (Nobel prizes aren’t lightly given, are they Mr. Obama?)

 

OR,

 

Is the black and white thing a farce?

Are (white ) Botha and (black) Zuma

the same colour inside?

The same as the Bushes, Clintons and Obama?

Quite unlike Jesus and Palme..

and Allende,  Gandhi and Sukarno?

(No wonder these latter had to be killed.

Guilty as hell, of being the wrong tint -

in their hearts.)

 

And where does our Premadasa fit??

 

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Funerals – for the birds?

 

A story on BBC today (http://www.bbc.co.uk/nature/19421217) describes birds holding ‘funerals’ for their dead.  This story caught my eye for the reason that it is unusual for bird actions to be noticed. We don’t really observe them closely and ‘bird-watching’ is often limited to identifying (rare) species. There are interesting things to discover by looking more closely at bird behaviour.

 

A bird bath is a source of easy observation (but needs of course to be drained regularly to prevent mosquito breeding). One discovery I made from looking at events around the bird bath at my window is that hardly any bird bathes before noon. A few have a quick dip around noon to 1.00 pm but nearly all bathers like the time 3.30 to 4.30 in the afternoon. I am curious as to this preference but have no way of inquiring from them. Can someone help?

 

Some birds such as the water hen love to linger in the water.  They seem to drag themselves out with great reluctance. Babblers and shrikes too spend a fair amount of time dousing, while the white eye plunges in and gets out fast. Flower-peckers, pigeons and doves, tailor birds, drongos, magpie robins, koels and orioles are quite averse to water. They will perch carefully and sip, all the while ensuring that no droplet touches their plumage. Crows prefer to avoid the clean water of the bird bath but can be seen washing in muddy puddles.

 

Individual differences in bathing practices are remarkable. They mimic the behaviour of human babies who hate their bath versus those who refuse to end it. A crowd of babblers descends and the more water-loving individuals quickly plunge in and start doing their thing. Many others soon follow. But a few are not too keen and keep hopping around the edge until, envious of the antics of their fellows frolicking in the water, reluctantly jump in – only to hop quickly out in a few seconds. A white eye pair is amazing in the difference between them. One of them eagerly plunges in and thoroughly wets itself and gives its wings a good wash. The other hovers at the edge and suddenly darts on to the back of its mate for a few seconds. It allows on itself a few drops of the sprinkle that the partner is producing and hops off, satisfied. I am now able to identify, from size and shape (for they are otherwise quite alike), which one will plunge in and which will desist, before they embark on their appealing routine. Mynahs don’t like to bathe but one individual alone, among those I see, likes to paddle in the bath.

 

Since birds show huge individual differences in how they relate to water, they must surely differ from each other in many other respects. Such variations can then be said to amount to differences in personality. We can easily recognize different personalities between dogs of the same breed but don’t readily notice the same occurrence within the rest of the animal kingdom. Do hardworking hyenas have to hunt for their slothful sisters too? Are some worker bees less prone to sharing nectar news with buddies? Can there be amoebae so selfish as to avoid the split?

 

Back now to those funerals. The recent influx of crows (and in their wake, koels) has spelt doom for most other species in the vicinity.  They are declining in number at frightening pace.  I’d like to see thousands of crow funerals happen before mine does.  (By hastening theirs, not postponing mine.)