To clone or not to clone
By Kamaleshwar Sinha
BETWEEN two popular umbrella statements, perhaps, lies the true nature of science. Herbert Spencer said that science is organised knowledge. T.T. Munger represented those who saw a sectional view in the philosophy of "an uncertain guess". The second view declared that science cannot determine origin and, therefore, it cannot determine destiny. "As it presents only a sectional view of creation, it gives only a sectional view of everything in creation". Science fiction came before science fact and this is why one is not able to "guess with certainty" where a golden chain of truth lies beneath a heap of facts.

Moderation: key to health
By Dr G.D. Thapar
If you were to ask me to name the single most important factor which is conducive to good health and long life, I would unhesitatingly say "moderation". by this I mean moderation in every human activity — eating, drinking, working, playing, exercising, resting, sleeping, sex, etc.

Breakthrough in organ transplant-II
And a contract was at hand
The eminent hand and transplant surgeons would fly into Lyons from around the world, sit in hotels overlooking the Rhone and twiddle their thumbs for 10 days at a stretch. This had happened three times since June.

Superbug tuberculosis: a millennial challenge
By Dr Ashok K. Janmeja

Tuberculosis (TB) was declared as a global emergency by the WHO in 1995. This was because of the fact that the world was facing a grave situation as far as the tuberculosis scenario was concerned. The following description, I hope, will give a bird’s eye view of the present TB problem. About one third of the world's population is infected by TB germs. Worldwide, there are about nine million new cases of TB with three million deaths annually. These germs kill more human beings than any other single infectious agent and deaths from TB comprise 25% of all avoidable deaths in the developing countries.

About 95% of TB cases and 98% of TB deaths are in the developing countries; 75% of these cases are in the most economically productive age group — 15 to 50 years. In India alone, one person dies of TB with every passing minute. By the time you finish reading this article, 10 to 15 persons would have left the world because of TB.

It is a leading killer of women, too, as it kills more women than any other infectious disease does. It kills more women than all causes of maternal mortality combined.

The Indian TB scenario reveals that our country accounts for nearly one third of the whole global TB burden. India has more cases of TB than any other country in the world and twice as many cases as China, which has the next highest number.

Approximately, 2% of the Indian population is suffering from this disease. The grave situation has been made more explosive by the recent epidemic of AIDS worldwide. HIV-infected persons carry five to ten times higher risk of developing TB than their counterparts who are not infected with the AIDS virus.

Thus the AIDS epidemic, if not controlled urgently, would rapidly increase the TB cases multifold.

Apart from the gigantic TB problem, which has now been complicated by the AIDS epidemic, the world of tuberculosis is facing a third serious threat in the form of the drug-resistant superbug tuberculosis. In the superbug-caused TB the conventional drugs fail to cure the patient and the highly simplified treatment regimens need to be replaced by more difficult, complicated, costlier and painfully troublesome treatment modalities.

The problem of drug resistant superbug is not unique to TB alone. Resistant germs are being encountered frequently in other infections too (typhoid, malaria and hospital-acquired infections, etc). The sole reason for the emergency of these drug resistant superbugs in general is the overuse or abuse of antibiotics by physicians and patients both. In spite of the experts have been spreading the message over and over again: the overuse or abuse of antibiotics fuels the rise of drug-resistance. People, however, still have not understood that antibiotics are useless against viruses, which cause most of cold, flu and other related illnesses.

What is multidrug-resistant (MDR) or superbug TB?

When the TB bacteria show resistance to at least two most important anti-tuberculosis drugs, viz isoniazid and rifampicin, they are termed as MDR-TB bacteria or the superbugs. Many a time these bacteria may have resistance to three or four or even five or six anti-tuberculosis drugs concomitantly. The use of these two drugs is crucial to the management of drug-sensitive tuberculosis, so much so that their deletion from the therapy will make the cure very difficult and delayed. The estimated prevalence of superbug TB amongst previously untreated cases of <1% in advanced countries and it could be as high as 2-7.5% in developing countries. Superbug TB is more commonly encountered among the patients who had been having repeated unsuccessful TB treatments — the old, active, pulmonary tuberculosis or chronic cases, in which the rate could be as high as 15-50%, in fact an alarming figure. Now the question is how and why do the fully-drug-susceptible TB germs transform into drug-resistant superbugs?

The phenomenon is basically manmade. The doctors and the patients both are responsible for the genesis of these monsters.

When a doctor gives a wrong prescription to a freshly diagnosed TB patient or when a patient does not properly adhere to rightly prescribed therapy, the initially drug-susceptible TB germs acquire resistance to commonly used vital anti-TB drugs. Inadequate TB control services, fewer well-trained doctors in modern chemotherapy of TB, the rampant practice of inadequate treatment by non-allopathic medical practitioners or quacks and the use of inferior-quality drugs are important reasons for the emergence of superbug TB.

Hurdles in the management of superbug TB: The treatment of superbug tuberculosis is highly challenging and quite different from that of TB caused by drug-susceptible germs. Of many, a few difficulties have been highlighted herewith. The total drug cost involved is usually 50-100 times that of susceptible bug tuberculosis, in which case it is around Rs 1500 to Rs 2000 only. Thus, the drug cost for the treatment of the superbug disease is forbidding to the majority of the poor patients. Also, the reserve drugs used in such cases are more toxic and carry a high-intolerance rate, which ultimately affect treatment compliance adversely. These patients are chronic cases and some of them have involvement of other vital organs like the kidney, and the liver. This further restricts the free and safe use of many vital anti-tuberculosis drugs.

Apart from the forbidding cost of these drugs, their uninterrupted supply in the market is not guaranteed. The total treatment length is 24 months or more four times higher than that of susceptible strain TB. This makes the therapy tedious and cumbersome. Lastly, the most unfortunate part of the story is that despite the best treatment facilities and best drugs in the best national or international centre, only 50% patients achieve cure.

The treatment of superbug TB: Because of the problems highlighted above, the treatment of superbug TB must be carried out under specialists in specialised centres. Before embarking upon the treatment of such cases, the first and foremost step is to devise an ideal drug regimen for an individual patient.

The regimen planning is based on a critical evaluation of many factors — past-treatment history, the drug-sensitivity pattern (if available), affordability, the availability of drugs, drug toxicity and HIV status. The personality of the patient and the will of his family to participate actively in the difficult treatment voyage are other important considerations.

Thus, a regimen planning for a superbug TB patient involves highly complex decision-making process and mistake at this stage can be fatal.

In the individual drug regimen three to five new anti-TB drugs to which the TB germs are likely to be fully susceptible are included. These drugs are given for three to six months in the intensive phase of treatment. Following the successful intensive phase, one or two drugs are withdrawn and the treatment is continued in the maintenance phase for a minimum of 18-24 months more so as to achieve complete cure. It is a must to assess the kidney and liver functions before switching over to reserve anti-TB drugs. A close watch on them is required throughout the treatment. The initial management of such cases should be done after admitting them in a hospital till they are stabilised. Superbug TB patients should be kept in an isolation room until they are assessed to be non-infectious. If possible, the whole intensive phase should be a directly observed therapy. The drug intake by the patient should be ensured by an observer or a responsible member from the patient's family or society. Unfortunately, most patients have advanced disease for lung surgery to be permissible. However, it can be considered when the disease is well localised, lung functions are adequate and the TB germs are resistant to all but two-or-three week anti TB drugs.

How can we prevent the superbug TB menace?

Complexities, prohibitive cost and the unfavourable treatment outcome of the entity clearly warrant that we should observe every possible precaution to prevent its emergence. For this, both doctors and patients have to respect the very basic, principles of TB treatment. For every infectious pulmonary tuberculosis case an effective regimen of short-course chemotherapy (six months or eight months) should be employed. Those who fail after the first course of chemotherapy, should be re-treated with the who retreatment regimen. Total prevention is only possible if the TB Control Programme is implemented effectively at the national level and all treating physicians handle tuberculosis rationally and honestly. It is quite understandable that when every new case of TB will be cured without any failure and relapse, there will be virtually no chance for the emergence of superbug TB. Therefore, the prevention of the superbug problem is our professional and moral responsibility to mankind.

Dr Janmeja is the Professor and Head of the Department of Tuberculosis and Chest Diseases, Government Medical College and Hospital, Chandigarh.

To clone or not to clone
By Kamaleshwar Sinha

BETWEEN two popular umbrella statements, perhaps, lies the true nature of science. Herbert Spencer said that science is organised knowledge. T.T. Munger represented those who saw a sectional view in the philosophy of "an uncertain guess". The second view declared that science cannot determine origin and, therefore, it cannot determine destiny. "As it presents only a sectional view of creation, it gives only a sectional view of everything in creation". Science fiction came before science fact and this is why one is not able to "guess with certainty" where a golden chain of truth lies beneath a heap of facts.

Think of Dolly, the sheep cloned in 1997 by a British pharmaceutical company. This first mammal of its kind became pregnant subsequently and gave birth to its first cloned lamb. Now pigs have been cloned—five of them! They have been thoughtfully christened Millie, Christa, Alexis, Carrel and Dotcom! They are seen as harbingers of a new era in mammalian reproductive technology.

Those who support therapeutic cloning while opposing reproductive cloning will have to reconcile themselves to a heap of facts that hides the golden chain of truth. The probable has become possible.

Why have pigs been chosen for cloned birth? The answer lies in constructive thinking about human well-being. Pigs have many biological similarities with human beings. With millions of people waiting for organ transplant all over the world, the value of modified pig genes is immense. The concept of xenotransplantation has reached the stage of successful implementation. Within a decade hence, the shortage of hearts, lungs and kidneys required for transplantation may be reduced considerably.

If research expectations do not go awry, scientists would use stem cells to grow heart cells which would replace the tissue damaged by a heart attack or produce nerve cells to cure Alzheimer's disease, for example.

For the present, it is necessary to understand the meaning and the message of cloning. Researchers are close to the phase in which one male pig and one female pig would be created and then through reproduction life would be able to defeat disease.

The concept is clear. Clone is a group of organisms that are genetically identical. Most clones result from asexual reproduction. In this process, a new organism develops from only one parent. One can leave enough scope for rare and spontaneous mutations. But asexually produced organisms generally have the same genetic composition as their parent. All the offspring of a single parent form a clone.

Single-celled organisms like bacteria, protozoa and yeast usually reproduce asexually. Drugs and other compounds are tested on bacterial clones. Farmers and gardeners raise apples, potatoes and roses by means of clones.

Techniques of genetic engineering enable scientists to combine an animal or a plant gene with a bacterial or yeast plasmid. By cloning such a plasmid, geneticists can produce many identical copies of the gene.

Can one call a cloned human embryo an ethical object? This is what the anti-cloning groups say in sum: "What people fail to grasp is that embryonic stem-cell removal involves the death of a human entity. Nobody should be a party to this kind of procedure. Any research using embryos has an ethical cost..." But stem-cell therapy has the potential of making a real difference to people's lives. Where do we go from these strongly held positions? To hope for life—present and future!

And thereby hangs a tale. A converted astronomer was asked to provide a comparative estimate of ethics (or religion) and science, which he had idolised for years. His answer was brief but categorical: "I am now bound for heaven and I take the stars in my way". Cloning for life's sake: this can be a reasonable motto for us.

Moderation: key to health
By Dr G.D. Thapar

If you were to ask me to name the single most important factor which is conducive to good health and long life, I would unhesitatingly say "moderation". by this I mean moderation in every human activity — eating, drinking, working, playing, exercising, resting, sleeping, sex, etc.

Most of our ills stem from the excess of one kind or the other. Even good things become harmful if carried to the extreme. And bad things become worse! Moderation prevents the damage done to the body or mind by wrong actions or harmful things and gives regenerative processes a chance to undo any damage that may have been done.

With moderation, you may escape adverse effects of harmful things altogether and may sometimes even earn some good. Alcohol is a notable example. In excess, its effects are devastating but in small doses it gives protection to the heart. Even smoking, which by all counts is a dangerous habit, may inflict little damage on an occasional smoker.

Excess of everything is bad, and, as said above, even of good things of life! Good food is necessary for the body and its lack causes malnutrition and poor health, but excess food reduces the life-span by hastening the process of cell replication which brings old age earlier. Sugar is a source of ready energy and reverses the effects of low blood sugar after exercise. It may be life-saving in the case of over-action of insulin. But the excessive intake of sugar and sweets leads to obesity and its consequences. Eggs and animal fats are sources of reserve energy and of cholesterol which forms part of every human cell, particularly of the brain and other internal organs. Animal fats are therefore a useful part of our diet but only in limited quantities; otherwise they cause obesity, raise the blood cholesterol level, clog the arteries with fatty deposits and are thus instrumental in the production of heart attacks and strokes. Salt is an essential constituent of blood and body fluids. Small amounts are necessary to replenish the salt lost in perspiration, but excess intake elevates bloodpressure.

High-fibre diet is healthy. It prevents cancer of the gut and keeps the blood pressure and blood sugar under control, but too much and too quick switchover to high-fibre vegetarian diet may cause gastric upsets in non-vegetarians and old people.

Tea in moderation is invigorating. Its antioxidant contents prevent diseases of degeneration but its excess may cause insomnia and palpitations.

Regular exercise within one's capacity is good for the health of the heart and is conducive to longevity, but excessive exercise may precipitate a heart attack. Excessive exercise causes oxidative stress and, when indulged over long periods, shortens life. Rest after work or exercise is necessary to regain the lost energy. It helps regenerative processes to take effect, but excessive rest is indolence and lethargy which encourages weight-gain and reduces life-span.

There is another cogent reason in favour of moderation.

Scientific theories sometimes change. If you take a moderate course, you will never go wrong too far. Not very long ago, there was much enthusiasm about jogging. Some people advocated it even for the elderly till some dropped dead. Moderation would have prevented such unfortunate incidents.

It is not necessary to dwell further on the merits of moderation to extol its virtues. Suffice to say that even too much concern and preoccupation with one's health is counterproductive. Take reasonable care of your health by inculcating healthy habits based on sound scientific principles, practise them and make them your second nature. Take timely help of medicines through competent hands when necessary, and forget the rest.

"The faithful yogi, striving for liberation, shuns gluttony, sloth, overwork, and starvation, Temperate in sleep, and all else he undertakes, He finds real peace, and higher consciousness awakes." — The Bhagavadgita.

The author is a former Director (Medical) and Chief of the Medical Unit at the Willingdon (now Ram Manohar Lohia) Hospital, New Delhi, and a consultant in Medicine and Cardiology at the INAS Hospital, University of Tripoli. He is now based in Ambala cantonment.

EXCLUSIVE
Breakthrough in organ transplant-II
And a contract was at hand

The eminent hand and transplant surgeons would fly into Lyons from around the world, sit in hotels overlooking the Rhone and twiddle their thumbs for 10 days at a stretch. This had happened three times since June.

Twelve days into the new year, the call came. A family had agreed. The key players were alerted immediately. Nadey Hakim, a multi-organ transplant surgeon at St Mary's Hospital in London, abandoned a lecture tour in California; Earl Owen, the sprightly 64-year-old Australian pioneer of microsurgery, flew out of Sydney; four Italian specialists drove from Milan to join Jean-Michel Dubernard, the head of transplant at Lyons' Edouard Herriot Hospital, and their French colleagues.

Their breakthrough was a long time coming and had not been without competition. In 1998, in the United States, a team announced it would perform a hand transplant. But Owen and his colleagues had similar plans, kept them secret and beat the Americans to it. The latter bit their lips, went on to perform the world's second hand transplant, then quietly prepared for the first double. Now they would be beaten again.

Hand transplantation is a procedure almost as divisive in medicine as cloning. Will a patient be able to cope psychologically with the constant reminder that "their hands have come from a dead person? Is it ethical to perform an operation that requires an otherwise healthy patient to remain on powerful drugs for the rest of their life? The need to suppress the body's immune system to prevent rejection means there is a very real risk of developing a range of different cancers.

The possibility of contracting Graft-Versus-Host Disease (GVHD), where the donated hand begins to reject the patient, attacking the skin, liver and intestine, is also a possibility. Then there is the grim thought of what may lie ahead; of braindead patients being shorn, harvested for their arms, legs and who knows what else.

Denis Chatelier, a 33-year-old house painter and father of two, whose hands were blown off when a home-made model rocket he was showing to his nephews exploded prematurely, needed no convincing. Chatelier had grown used to the shouts of braz d'acier, metal arms, from cruel youngsters whenever he ventured into his home town of Rochefort, on France's Atlantic coast. But he yearned to hold his two young children again, to live a normal life. When he saw a television report of the first single hand transplant in 1998, Chatelier contacted Dr Dubernard.

The two met early last year, along with Chatelier's GP. The house painter described himself as un battant, a fighter, and un croyant, a believer. After his accident he had taken up jogging, and he was in good shape for a gruelling 17-hour operation and up to two years of physiotherapy. Dubernard agreed to go ahead, sensing in Chatelier the spirit of a marathon runner. "He is strong-willed, tenacious," the surgeon told colleagues.

(To be continued)