One full-page article in one of India’s leading dailies, in its health section, caught my attention while travelling the other day. It was all about the poor Indian heart that is supposed to be specially vulnerable to heart attacks in young age vis-à-vis the strong western heart and so on and so forth. The usual textbook picture of a red heart cut open along with five illustrated cardiologists whose considered opinion the lay reporter of the paper converted into this juicy article. This myth is being trumpeted from housetops by the profession, aided and abetted by the multibillion-dollar pharmaceutical and technology industries. This world is a wonder. Where is the reality in this world? The truth is the first casualty here. Much as I would have loved to believe this message, I am afraid, I have a duty to my countrymen to give them the other side of the coin for them to make their own judgement. There is a lot “more beyond”-plus ultra.



Health education of the common man should aim at, if anything, reducing anxiety. In essence, the whole medical world revolves round anxiety. There are primarily two types of anxiety-the patient anxiety of disability and death, and the doctor anxiety of have I done enough or do I do more? If some one could find a drug or surgical technique to manage these two sets of anxiety mankind would have had peace. On the contrary, the poor reading public, especially in the English press, is daily being given large doses of anxiety by way of this kind of half truths and myths that abound in medicine. Thank heavens, the large majority of our people are illiterate, although well educated. They are immune to this attack! The whole area of heart diseases is shrouded in mystery and it needs a medical Gorbochev to demystify the air.



Health is one’s birthright. Diseases are accidents. Just as one could reduce traffic accidents if one follows the road rules correctly, one could hope to live well for a long time if one follows the simple healthy life style. Many a time one does fall ill because of extraneous factors, like any traffic accident due to the negligence of other road users. Healthy life style is simple to follow. Clean good food in small quantities many times a day, enough water intake, hard work which one loves, positive attitude to life, avoiding negative feelings like hatred, greed, jealousy, anger and frustration with depression, courage to forgive others, trying to be of use to others in distress, enjoying what one gets, and ultimately treating others as our own kith and kin, should keep one healthy. Death being the only certainty, it can not be avoided, though.



In the unlikely event one falling ill one should not fail to get the help of a good placebo doctor in time. Self-medication is dangerous. Delaying consulting a doctor, when in trouble, could also be a bad habit. However, seeing doctors or getting routinely screened when one is perfectly healthy, energetic, and enthusiastic could be dangerous, as shown by many studies reported recently in the leading medical journals. Just as one could have a traffic accident due to the negligence of other road users, doctors and their interventions could also cause harm! A total of 1,00,000 deaths occurred due to medical errors in a country like the USA in one year! Recently, when doctors went on strike in Israel, death rates fell significantly, only to come up again after they resumed work.



Let us now confine our discussion to the heart. Many questions beg to be answered to the extent possible from latest research. The distilled wisdom of those findings would take decades to come to the medical textbooks or reach practising doctors. One should keep in mind that any science, medical science included, keeps changing very fast. One has to keep in touch regularly to be well informed. I strongly feel that it is the duty of medical world to inform the common man about the fruits of latest research to allay anxiety to the extent possible. I shall try to do that in the following narrative.



Has the incidence of heart disease increased recently?



The simple answer is NO. What has changed, though, is its awareness in the medical and lay world. This is called labelling. Diagnostic refinements with new classification of diseases has created this myth. More and more people, mostly the apparently healthy population, are being goaded to go for a check up and are then labelled. In addition, the actuarial figures have changed with the human death pattern having drastically changed in the last few decades, because of the remarkable reduction in the killer infections in children all over the world. Vaccination, better living conditions and, good food with improved hygienic surroundings have been responsible for people not dying mostly before the age of twenty.



Naturally, the number of people above the age of thirty has gone up exponentially in most parts of the world including India. Most degenerative diseases are natural as age advances. There is, therefore, a relative increase in the eligible population. It is expected that in the next fifty years nearly 70% of the population in Europe would be above seventy years! Our life expectancy was 27 years in 1947 and is nearly 67 now. Naturally, we have a large population of eligible people to get degenerative diseases.



Wrong labels are another menace. Everyone today, going for a check up is advised to have the blood vessels x-rayed with a dye, just in case. This makes good business sense, though. Doctors use the words coronary heart disease and coronary artery blocks interchangeably. Nothing could be farther from the truth. Blocks in one or more of the larger surface coronary vessels seen in the x-ray (angiogram) are a normal phenomenon in those who have inherited the necessary genes even as early as fifteen years of age. Scots and Finns have a very high percentage, while the French have much less blocks with the Japanese still less.



While we do not know anything about Indians, we still frighten people out of their wits based on these x-rays. Large percentage of young American soldiers who died (average age 18 years) in the Korean and Vietnam wars had these blocks postmortem. They were in the pink of their health to be sent for fighting. Black children, as young as ten years, had blocks on postmortem. They were shot dead in the crossfire in Los Angeles riots a few years ago. Blocks in the coronary surface vessels are not synonymous with disease. Coronary disease comes when the small perforating vessels (millions of them) lose their inherent capacity to dilate to supply more blood to the heart muscle in need during exertion or when the blood supply is cut off suddenly in an, otherwise near normal, large surface vessel. This clot rarely comes on in a significantly blocked vessel seen in the angiograms. Doctors’ judgement that one is sitting on a volcano threatening to burst anytime based on those blocks, would send fear down the spine of the poor victim and his/her relatives.



An exhaustive study over a period of five years, by a NewZealand pathologist, Stehabens WJ, did not show even 1% absolute increase in coronary artery disease in the west in the last one hundred years. The increase, if any, was only relative. Even the world population has increased in the last fifty years making the number of people with any disease look much larger compared to the past. Most Indian young men, studied for precocious heart disease, have failed to show any link to any of the conventional risk factors talked about. Genetic factors and the emotional trauma of acculturation to a new country have been blamed. This has been the experience of immigrants from Polynesian islands to the US, and the rural folk migrating to cities in Chile. Latest research all over has pointed the finger to the human mind and its negative feelings as the main culprits in killer diseases. This area is crying for further clarifications. Unfortunately, research money does not flow in there. Interventional methods to change the human mind may not be as good a money-spinner as drugs and surgical interventions.



Are heart diseases new?



Far from it. They are as old as mankind. Ayurveda has a better description of the presentation of coronary artery disease, which is yet to be bettered by modern medicine. Vascular diseases have been discussed as far back as 1733 AD. by Charles Scharshmidt, in Vienna, in his textbook of medicine; probably the first in modern medicine. Even his treatment seems more modern than ours: change of mode of living, vasodilating drugs like nitrates, and tranquility of mind! The earliest recorded patient with a heart attack in China was a lady aged 39, whose body was found hundreds of feet under the snow. Her body was carbon aged to be around 2500 years old. She had a massive heart attack with a large clot inside a normal looking anterior descending coronary artery. The only thing that has changed over the years is the presence of relatively larger number of human beings on the planet. As explained earlier many of those thus labelled were not suffering from coronary disease.



What role does the human mind play?



Modern medicine suffers because it did not branch off and follow the modern particle physics in the early part of the twentieth century when the latter realized the futility of linear conventional physics in explaining the ways of this world. We are still following the linear laws in medicine. Human mind, consciousness, is not an organ-based concept like the heart or the lung. Mind is present in every human body cell, of which there are one hundred thousand billion in all. Mind, like the lepto-quarks (smallest particle of an atom), is interconnected and interchangeable. Mind is where the seeds of all diseases start. They only grow in the body using the environment and the genes as fertilizers, to cite an agricultural analogy. In this concept no two individuals are alike and each needs tailor made management strategy. Camp approach that we follow in modern medicine does not help very much. To understand any disease, the doctor should be able to fathom the human mind to the extent possible. The modern significance of negative feelings as the leading risk factors for major killer diseases has been found out by studying the role of human mind in illnesses. Rather, it is the mind that needs solace much more than the body. Interventions help in the acute set up only.



Apart from the large body of retrospective studies linking the mind and the heart, we now have a prospective study from an American University. Young students in their teens were asked to keep an honest diary of their hostility scores. They were screened for damage to the coronary arteries serially once in six months using the positron emission tomogragy based on calcium deposits. At the end of five years there was a definite parallelism between the hostility score and the amount of damage to the artery. Mind runs the body.



To heal one needs to take a holistic view of illness and wellness. Wellness is a concept alien to modern medicine and so is the word healing. There are ongoing two interventional studies trying to give solace to the disturbed mind in the management of coronary artery disease. We shall watch and see their outcome after three to five years. Interim reports are encouraging! The ancient methods of Yoga breathing and meditation have already been shown to be very effective in intractable coronary disease. More surprising is the finding that intercessory prayer has been shown to be very effective in lowering death and disability after an acute heart attack. This brings us very close to particle physics of quarks. Modern rat race in migrants of Asian origin in the west is killing. The western culture of destroying others to build ourselves (hostility) is new to the Asians who are born and brought up in altruism and co-operation. This is the unseen hand mentioned earlier in the Wembly study and many other studies of young immigrants succumbing to precocious coronary disease. Let us not replicate it to the youth of India and instill fear into the younger generation here. Fear is the key to illnesses. Indian culture of yore, of paropakaarartham idam shareeram should, keep the coronary arteries out of trouble. Let the younger generation have this self-knowledge right from elementary school. Let us live and let live. Coronary disease would be defeated to a large extent.



What of the genes?



Our dream of discovering a gene for every disease and, then trying to set it right using genetic engineering, has not been realized yet. Reality is that there are only about 30,000 odd genes in all and they would not go round one for each disease. The second dream has just started after the failure of the first one. New HAPMAP is looking for groups (haploid) of genes to see if those groups could be manipulated to help groups of diseases? Let us wait and see. Predicting the future is dangerous, if not impossible. However, enthusiasm is very much in HAPMAP as research dollars are plenty there. It is a one hundred million-dollar project! At the end of all that we would be back to the square one.



Even the genes are under the control of the mind. Nobel Laureate Barbara McClintock showed long ago that one could change the genes in the progeny by trying to please the mind of the parent. She called it the jumping-gene hypothesis. Mind is the supreme authority in illnesses.



Pre-natal origin of diseases.



If one were to believe David Barker of Southampton University and his hypothesis, one could easily explain the increased incidence of coronary disease and diabetes etc. based on his hypothesis. Mothers whose nutrition in the first trimester of pregnancy is poor for any reason bring forth babies that are made defectively. If such babies, when they grow up, get themselves transplanted to a (junk) food plenty atmosphere they could quickly become diabetics and have precocious coronary disease. There are dissenting voices, feeble though, against this view. The fact remains that we have inherited what are called thrifty genes because of our hunter-gatherer habitat in the past. It is only in the last few decades that we have put ourselves into this food-plenty environment. The gene-food mismatch has an important role to play in illnesses.



Are modern medical interventions useless?



Never. They are very useful in any acute emergency and could even be life saving. What is bad, however, is their use in apparently healthy population and their overuse on the long-term basis. Coronary interventions are a great boon to the patients in pain and distress. They get a new lease of useful life and, in some small cohorts, even projected statistical benefit in longevity. Even in the emergency situations judicious use of intervention is useful. Overuse even there could be disastrous. A recent study showed clearly that bypass surgery in the immediate post-infarction period is the cause of four-fold increase in stroke deaths in the next six months. In fact, statistics showed that the greatest risk factor for stroke now seems to be getting admitted after a heart attack to a hospital with angiographic facility. Multivariate analysis showed this risk to be much higher than all the known stroke risk factors! Comparison of two large identically comparable cities in the US and Canada for their intervention rates showed that in the US, despite a ten fold increase in interventions, death rates in both the places remained identical.



Still more glaring example is the comparison of Vietnam and Falklands war casualties. Whereas the most modern US base hospital was so close in Saigon that most wounded soldiers received “best” interventions within hours after serious injury, the British soldiers, on the contrary, in Falklands were, at times, left in the open snow for hours before being taken for help. There was no base hospital worth mentioning in the vicinity. At the end of the day the mortality was marginally better in Falklands! There are good reasons for that. Nature has built in enough emergency protection. Many times we disturb nature’s healing capacity and get into trouble. Judicious intervention in an emergency could save lives, while unnecessary interventions could harm the system. Modern medical interventions are a panacea for emergency care but, in long-term management we must be very careful in intervening-going in between (nature and man) with malice. Long live modern medicine and mankind. Let us not make people more anxious. “Epidemiologists could cause epidemics,” by instilling fear in the masses.



Moral of the story is that there is much more to the whole story than the conventional risk factors that are being advertised everyday. There is more beyond-plus ultra.