FULL TRANSCRIPT OF THE RECOMMENDED DOSE WITH RAY MOYNIHAN - Episode 6 Prathap Tharyan
24 November 2017
Ray Moynihan: Yeah, g'day. It's Ray Moynihan and another episode of "The Recommended Dose." Today, we're very happy to bring you a conversation with Prathap Tharyan, the Indian psychiatrist who really wanted to be a traveling DJ but ended up as a leading voice pushing for better use of evidence in healthcare.
Prathap Tharyan: I lost my dad when I was very young and I had to get involved in supporting the family and becoming more responsible. [00:00:30] Even though my inherent desire was to be a disc jockey or a traveling disc jockey, moving all over the world, I had to kind of balance these ambitions.
Ray Moynihan: Prathap Tharyan is a professor based at one of India's top medical schools, the Christian Medical College, and he's Director of Cochrane South Asia. Cochrane being the global collaboration, which produces summaries of evidence to help inform our decisions. The power of looking for and using [00:01:00] good evidence is twofold. It can help show us what treatments work and how well they work, and they can also show us that what we think is helping people might, in fact, be doing them more harm than good.
Back in 2004, many will remember the devastating tsunami of December 26. One area hardest hit were the communities on the Indian Coastline, close to where Prathap was working in Vellore in Tamil Nadu.
Prathap Tharyan: On Sunday morning, [00:01:30] I put on the TV and saw this news about this horrible calamity. My sister was in Shanghai, I rang her up. It was chaos. Everybody was devastated because we had never heard of a tsunami before, we didn't know what a tsunami was. The whole nation sprung into action as did the rest of the world to try and help the victims of the tsunami. Our Chief Minister asked for help from all medical institutions to provide physical as well as psychological support.
After the first team of volunteers [00:02:00] from CMC went out there, we were asked as a Department of Psychiatry to provide counseling support because the media were full of reports that people are likely to be badly traumatized by the tsunami. They lost lives, they lost their property, their entire belongings. About two weeks later, I took a team of about 10 psychologists, social workers and doctors and went down there. It was devastating to see the acute, traumatic situation everybody was in. Lots of people had lost their lives [00:02:30] and property. About 40,000 people were living in displacement camps, a little away from the shoreline.
We really didn't know what to do because it was a huge human tragedy, but the government was trying to organize counseling services. The problem was we really didn't know what to do. We'd never faced this kind of a situation. The mental health team was of the opinion that we should provide mass debriefing to everybody in the [00:03:00] villages because that was a model that was being used in many parts of the world in traumatic and post-traumatic situations.
Ray Moynihan: You were asked to do sort of psychological debriefings or counseling for everyone, is that right?
Prathap Tharyan: That's right. That's the model that was being suggested, but I had my doubts about this because I said, "I don't really know the evidence for this." I also felt that in a natural disaster situation, in the immediate aftermath, the stress is common here, [00:03:30] and the human organism needs time to absorb this and reconstruct a world view. People here have different ways of dealing with community-led trauma. They band together. They're not isolated, they work together.
I was doubtful, so I thought one of the things we need to do is to see if there's any evidence on what should be done in situations like this. Fortunately, I had my laptop, which also had a CD-ROM version of the Cochrane Library. I looked for interventions in post-traumatic [00:04:00] stress disorder, and looked particularly for debriefing. I found a review, which cast a lot of doubt on the usefulness of this, in fact it suggested, from a limited number of studies, that it might actually cause harm because we are just going in there, sensitizing people to a traumatic situation and walking away.
I found other evidence in the Cochrane Library, which suggested repeated sessions with people who are particularly vulnerable might be a better way of dealing with this. We had this [00:04:30] big policy decision on what we should do in terms of providing counseling services. We decided the best thing to do is just look for people who appear vulnerable, support them and desist from attempting to debrief everybody because it's a colossal job. There were 93 villages and we didn't have enough resources. In the end, that's what we did.
Ray Moynihan: Six months later, Prathap's team returned to the villages affected by the tsunami and conducted both qualitative and quantitative research. [00:05:00] They found both community change and cohesion, reinforcing their decision to avoid the mass debriefing of everyone, and focused instead on offering psychological and practical help to those who were most vulnerable.
Prathap Tharyan: Most people had recovered in about six months, except for the ones who had lost loved ones. Some of them were going through a bereavement process, so we were trying to disentangle what happens in situations like this. How can community support be strengthened? How [00:05:30] can social structures actually be beneficial? In fact, in many situations, people are better off because of their social cohesion and because of their restructuring of their societies.
They address problems like alcoholism, like women's rights, like inequity between families and class based on income and religion. It was actually quite a learning experience to see how communities can rebuild themselves after such a traumatic situation.
Ray Moynihan: I think I'm right in saying, Prathap, that this [00:06:00] experience spurred you and colleagues around the world to push for better evidence to be available to help those that were preparing for disasters and responding to disasters.
Prathap Tharyan: Exactly.
Ray Moynihan: I think that led to the Evidence Aid project.
Prathap Tharyan: That's right.
Ray Moynihan: Can I just quote from that Evidence Aid website. It says, "The evidential message is clear. In the aftermath of a trauma, people need the support of trusted colleagues, family and friends. [00:06:30] They do not need trained counselors."
Prathap Tharyan: Exactly. That's exactly what we felt. The other important thing was what struck me when I drove into Nagapattinam in those days was there was a lot of aid that had been sent from around the world, which was totally inappropriate to what was required. For example, I saw lots of clothes lying around. Very good suits and jackets and ballroom dresses. I even saw a ballroom dress, but this community that this aid was [00:07:00] being sent to were fisher folk. They don't need ballroom dresses, they don't need clothes like this.
It seems like very well-meaning efforts in the aftermath of natural disasters in situations like this need to be thought through and they need to have some evidence for what we need to be doing, which is what led to the crystallization of Evidence Aid, is a required organization to help aid agencies and humanitarian efforts. I'm quite impressed with how [00:07:30] the project has continued to move on and has got people from Oxfam and many of the aid agencies to actually think of what evidence needs to go into their manuals, which their field workers use.
Ray Moynihan: I think you would also like to see a kind of fundamental change in the narrative, that the narratives that are often used around disasters, particularly in the media. Again, I'm quoting from the Evidence Aid website, "A wealth of evidence shows that people are far more resilient [00:08:00] than the media suggests."
Prathap Tharyan: Yes, that's exactly right. I think that I was very impressed by the societal change that occurred when people started reevaluating what their lives meant and in our kind of cultures, it was very clear that they are far more used to depending on traditional support systems than a mental health counselor because privacy and the way people express their grief is very public here. It's not a private thing a person is suffering through. [00:08:30] What they really needed was practical support. Help in terms of financial aid and resettlement in the immediate aftermath.
Of course, there are a few people who will need long-term support when they've lost loved ones and they're going through a process of bereavement. It was traumatic in origin, but the process and evolution of it is normal, it's a normal process. Normalizing the actions and focusing on building up resilience, I think is a message that Evidence Aid got from this episode.
Ray Moynihan: This is an incredibly interesting [00:09:00] discussion, Prathap. Not just because it's about the importance of evidence but I think you're saying something quite fundamental about medicine itself. Just to remind the listener, you are a practicing medical doctor and you're a psychiatrist. Do you see this as emblematic of a deeper problem within medicine and healthcare? That in our excitement to celebrate the wonders of our treatments and technologies, we lose sight of the resilience [00:09:30] of the human being and the capacity of the body and the mind on many occasions to heal itself.
Prathap Tharyan: I agree with you totally, Ray. I think you've also written on this whole issue on how we tend to medicalize problems, which are, some of them are fundamentally inherent to the human condition. We always think that we've get technological solutions to help us to live longer and forever. That illusion is what drive the medical field, the scientists and the clinicians themselves to seek [00:10:00] for remedies, which are totally senseless.
Unless we keep checking to see, "Are we doing the right thing? Really, "Have we got the question right? Have we got the answers right?" I think we'll keep running after illusionary dreams of immortality and everybody can live very happily, as long as they want. It's an aspiration, but I don't think that's the right way to go. I think we have to be realistic about how the human condition can be changed by more simplistic solutions and not necessarily technology. [00:10:30] I'm not against technology, but the appropriate use and misuse of technology is what bothers us.
Ray Moynihan: You're listening to Professor Prathap Tharyan, a leading Indian scientist who promotes better use of evidence in healthcare. One of the fascinating projects he's helped initiate is a new collaboration between Cochrane, the not-for-profit funder of this podcast, and Wikipedia.
Prathap Tharyan: Well, it started when one of my [00:11:00] colleagues, Dr Manu Mathews said, "Listen, I've been looking at Wikipedia, and I think that there's a lot of information out there, which we need to get involved with." We did a little survey and we found that actually, yes, there are people with a Wikipedia as well. In fact, if you look at the vision statement, their vision statement is, "Everybody should have access to the sum total of all knowledge, which should be freely available to everyone."
If you look at Cochrane's vision statement, "We wish to have all healthcare freely available. The knowledge [00:11:30] should be available in order to inform your healthcare decisions." We thought that there was a synergy between these two organisations. We also realized that most people, when they fall ill, don't want to look at the Cochrane Library. They go and look at Wikipedia because people would like to have, in one place, a little description of the disease and the complications and various things, and then, "What we should be doing about it?" Which Cochrane doesn't do, Cochrane doesn't give you that sort of information from a layperson's perspective.
It seemed like a good way to see whether we can populate Wiki articles with [00:12:00] evidence, which is reliable. We're also very encouraged that Wikipedia, in their policies, very openly said that they are interested in systematic reviews. It seemed like a knowledgeable bunch of people we were starting to work with. A little project transformed into inviting them for a plenary session at one of the Colloquia and talking about this partnership, which of course was then, we progressed to a formal relationship between Wikipedia and [00:12:30] Cochrane.
In one of our Colloquia, which we hosted in Hyderabad, we actually found a way in which we could have spaces where young people who want to get involved in learning how to edit Wikipedia, we had workshops for them. That's continued so lots, and a lot more people are empowered to use reliable evidence to populate Wikipedia. The Wikipedia Health Project is, I think, a great thing that's going on, and it's got so many more people taking over. What we've done here is [00:13:00] initiate something, which has gone somewhere that's good. We're really happy that we could be in this position.
Ray Moynihan: What about the tangled relationship between science and religion? You're clearly a very rigorous scientist. You're running the Cochrane Centre, you're at the heart of a leading medical school there, yet you work in a Christian Medical College. How do you integrate faith and science?
Prathap Tharyan: I often find that there's [00:13:30] a tension between religion and science. People tend to have different theories and different ways of approaching it. My take on this is that both science and religion are trying to answer quintessentially the same questions. "Who are we? What are doing here? Where do we come from? Where are we going?" We take different approaches to find this answer. Science uses the methods of science, which is redefine, we should be really redefining research [00:14:00] as not just an attempt to derive, generalize the new knowledge using rigorous methods and hypotheses, but we should also add this other right of, "For what purpose?"
If you redefine science, if you want to do these things in order to understand the human condition, and to maximize human potential, then we become closer to what a philosopher or a man of faith is trying to do. It's not often that science puts that condition. Science often just does science for the sake of science and it can become commercial science, [00:14:30] it can become something like what happened after the Holocaust, where scientists used very rigorous methods to derive very unfavorable outcomes to humankind.
Once we define what science is meant to be doing, trying to find out, "Who we are, what we're doing here and how can we all live together and how can we be happy?" Then I think these two approaches are fairly similar. Our methods are different, our theories are different, but I think in the long-run, we are trying to understand.
Ray Moynihan: [00:15:00] Prathap, I've been reading a lot about your work, and it's very pleasing to be finally talking to you today. I think I'm right in saying that you are a very dynamic person. There's a whole range of fascinating projects that you're engaged with, that you've initiated. You're an independent thinker, you're an iconoclast, I would argue. Where does that come from? I mean, if you agree with that assessment, where does that come from? What [00:15:30] drives you to think outside the box in terms of your own personal history?
Prathap Tharyan: Well, I think that's a ... I'm not sure I agree with everything that you say. Yes, I do a lot of things. That's largely because I've reached the age where I've retired from clinical work, although I still continue to do academic and other works with the Christian Medical College. A lot of people have asked me, "Well, how can you retire?" I realize the problem is most people identify, their own identity comes from the work [00:16:00] they do. I've always thought to myself, "No, I am Prathap. Psychiatry is one of the things I do. I do many, many other things." I always felt that that's what people should be doing.
We've been boxed into certain occupational roles, which take our entire lives. We don't realize that there are so many other facets to every human being that can be explored and put to good use. I think it stemmed from the fact that I lost my dad when I was very young, and I had to get involved in supporting the family and [00:16:30] becoming more responsible. Even though my inherent desire was to be a disc jockey or a traveling disc jockey moving all over the world, I had to kind of balance these ambitions.
I also had to be with my sister, who had poliomyelitis, paralytic poliomyelitis, and had a very difficult childhood. I learned what resilience was on seeing how she dealt with her life. Therefore, I have this immense belief that there's good in a lot of things [00:17:00] that happens, even though terrible things happen to people, there's so much good we can do. I have this immense faith that if you focus on the good aspects of people or situations, things work out in the end.
To make that answer brief. One, we are all individuals. We should not define our identities entirely by our occupations. We should be looking at, "How can we use our talents or interests in diverse ways?"
Ray Moynihan: Why psychiatry? Why did you end up ... You obviously trained as a doctor and then must have specialized [00:17:30] in psychiatry. Given your interest in social connections and community resilience, public health, why psychiatry?
Prathap Tharyan: Well, I think after I graduated as a physician, I actually wanted to do psychiatry initially, but I got fascinated by science, by biological sciences. I actually applied to be a neurosurgeon, and I worked in neurosurgery for some time before I realized that I missed the human connection. I missed the ability to treat people beyond medical [00:18:00] models, I needed to see a person behind that.
In psychiatry, I found something very closely akin to what a priest might find. I think psychiatrists, in some ways, straddle the boundaries between being a priest, philosopher and a medical person, and I find that fascinating. I think sometimes I'm so privileged that the relationships I have with people who come to me for help are so intimate in the fact that they reveal themselves to me, and it's such a [00:18:30] great privilege to be invited into somebody's inner-life. That really, really makes me feel good.
Ray Moynihan: Do you want to share any examples of those connections? Anything that particularly comes to mind now?
Prathap Tharyan: Yes. I did have one really moving and powerful encounter in my life where a young medical doctor was referred to me by my boss because he had an obsessive, compulsive disorder, which had been going on for five years. He [00:19:00] was a Muslim gentleman, about my age. In the course of treating him using the usual biological and psychiatric approaches of drugs and behavioural cognitive therapy and stuff, I discovered that this person's problems stemmed from the fact that he and his wife, young wife, had a small quarrel on one day when he had come back from work after being away for two weeks.
His young wife wanted to talk to him, but unfortunately for him on that day, India was playing [00:19:30] Pakistan in the World Cup cricket final, and he wanted to watch the match. This young girl went and immolated herself in the kitchen and died about a month later. In the process of working through his grief, he came to realize that God had given him, Allah had given him such a lovely girl, and because he was not a devout Muslim, he ended up losing her. He tried to make a bargain with God.
All of these are symptoms of grief, bargaining that, "If I were to become a [00:20:00] good Muslim, will you give her back to me in some form or the other?" I discovered that every bit of obsessive and compulsive ritual that he had was part of this process of purifying himself before he prayed so that God will accept his prayer. Having a lot of doubts, whether he prayed properly, having to repeatedly cleanse himself through the eyes of Allah. In that entire encounter, I realized the same common humanity that we have.
I discovered, I traced back within the history of the Christian [00:20:30] movement or from where the Jews and the Mohammed and Islam started. I was able to point out to him, in the Quran they talk about the God of Abraham. The Jews talk about the God of Abraham and the Christians talk about the God of Abraham. We had this wonderful discussion, and that helped him to realize that it was not God or Allah who has not forgiven him. He has not forgiven himself, and that was the start of him getting better. Where [00:21:00] in any branch of medicine will you be able to get into a person's mind and his way of looking at God and have a discussion? That it is very, very intimate, and he's doing extremely well now.
Ray Moynihan: You're the second psychiatrist we've had on this podcast, on "The Recommended Dose." We also spoke with Allen Frances. Do you share his views that psychiatry has become far too close to the pharmaceutical industry?
Prathap Tharyan: Oh, definitely, definitely. [00:21:30] I think that in the process it's lost a lot because I think appropriate use of pharmaceuticals I totally agree with. I do not believe that psychiatrists can get some forms of disorder well at all, but we also need to realize that this happens to a person. The relationship with pharmaceutical comes from the sale systems that drive it, that permit you to use a commercial model of healthcare, where drug companies in India [00:22:00] very often own many of the doctors who prescribe medicines. There's such a close relationship between psychiatry conferences and drug prescribing. I think people are trying to address it, but it's still very, very deep, this nexus.
Ray Moynihan: Rather than working closely with drug companies, Prathap has been engaged in innovative community-based initiatives, like the one a few years back when a non-government organization wanted help with an unusual model of care for homeless people with mental illness. They ended [00:22:30] up coming to Prathap and his wife, Anna, who's also a psychiatrist.
Prathap Tharyan: They couldn't find government psychiatrists to help them out, so we volunteered. Anna took over this program, and what happens is she works with local volunteers. There are two models of care. One is the model that is done in one of the towns, where with government permission, they've got a home for rehabilitation, psycho-social rehabilitation, run entirely by non-governmental workers with input from psychiatrists from our Center.
[00:23:00] They are far more effective in dealing with problems and their overheads are so low. It's a kind of a community-based model where they help each other, they bathe people. They look after them on the streets, and they reunite them with their families. We just support the program, we don't take over. We make sure that things are being done well and we support them.
The other program is how Anna and the local NGO have managed to identify people in the community who are willing to [00:23:30] look after mentally ill, homeless people in their vicinity by giving them clothes, food, shelter, as and when they need it, and sometimes without any medicines. In some situations, almost like can the society tolerate a person who's unwell, help the person, but don't necessarily interfere and try and cure him?
For example, there was a lady who lived under a tree, who was being looked after by a local shopkeeper, and he kept supplying her [00:24:00] notebooks because her occupation was to apparently keep accounts for the government of India. A far as she was concerned, in her illness, she had this fabulous role of running this country's economy. The big dilemma there was, "Do we treat her and get rid of these kind of beliefs, so that she can realize that she's an old woman with nobody in her life, or do we support her and let her live her normal life?" That's the kind of interesting dilemma we [00:24:30] have to deal with.
It was beautiful to see the community come around. They allowed her to live on the streets under a tree. They fed her, they clothed her, they gave her whatever she wanted. She lived life in her own way. She didn't disturb anybody else. Eventually, when she became too frail, the community got together and got her admitted into a hospice, where there's some nuns who helped her to live and die a good a death. That's the kind of models that we're trying to work with here. Anna is, I think she [00:25:00] found such a lot of rejuvenation, again, from the typical world of doing rounds in the hospital. You find there are so many people out in the community who don't have access to your hospital and don't want to come there.
Ray Moynihan: I think Anna, your wife, who's also a psychiatrist, has made the observation that while science and evidence are utterly important in medicine, what's also very important is to act from the heart. Do you see a tension? Is this a tension [00:25:30] in your practice between evidence and your need to act as an emotional or moral agent?
Prathap Tharyan: I have no doubt about it. I have no doubt about it. I think psychiatry as a whole stems from this contractual doctor, patient relationship, which is important. We have to make sure the boundaries are not blurred, so there's no crossing of boundaries and violations of boundaries. Ultimately, unless you can realize that this is an emotionally filled relationship as well, [00:26:00] you're not going to give people the permission to tell you how much they suffer. You're not going to really be able to empathise with the person suffering unless you realize a bit of yourself in him.
Sometimes when you talk about us and them, we surely forget that it's us and us. This could happen to any one of us. I don't have any qualms in looking at it from the point of view of saying that it might ... In our kind of setting, it's not unusual for patients to come and ask you, "Where are you from? [00:26:30] What are you doing? How many children do you have?" Which in many other Western societies would seem very intrusive. You don't do stuff like that, but here it's expected. That tier of involvement with each other, I think allows you to act from your heart.
Ray Moynihan: Just before we move on, I do like to ask our guests on this program for any book recommendations. My knowledge of Indian literature is appalling, and often involves authors [00:27:00] who've actually been born in India and left. People like Mistry and Adiga and so on. Do you have any recommendations, Indian or otherwise for any good fiction you've been reading?
Prathap Tharyan: There have been many Indian writers. One I just finished reading, of course, well known Arundhati Roy, who wrote "The God of Small Things." She's written the other book recently. She's a very powerful writer. [inaudible 00:27:25] emotional approach, but not afraid of facing [00:27:30] controversial issues that beset our country, and trying to highlight divisions within people, hypocrisies, and very, very concerned about the environment and the way draconian laws can be passed that are disadvantages to people. Arundhati Roy is a very good person to read.
Ray Moynihan: That's a good recommendation. I'd like to also recommend a British writer called Sarah Moss, who manages to weave in a lot [00:28:00] about medicine and healthcare into her novels. I was very excited to learn today that she may well be a future guest on The Recommended Dose.
Prathap Tharyan: Oh, wonderful, wonderful.
Ray Moynihan: Sarah Moss. Prathap, I'm not sure I heard it correctly, but did you say earlier that you were, one of your aspirations as a young man was to become a DJ and travel the world, is that right?
Prathap Tharyan: That's right. I wanted to be a traveling disc jockey. I wanted to yoke a Harley Davidson to a caravan and broadcast beautiful music to everybody in the world.
Ray Moynihan: [00:28:30] Well, I also wish you luck with that aspiration to become a DJ. You might know that a former DJ has just become Prime Minister of New Zealand.
Prathap Tharyan: Right, yes.
Ray Moynihan: Perhaps we'll see you at a nightclub somewhere soon.
Prathap Tharyan: Thank you, Ray. Thank you. It's been a pleasure talking to you.
Ray Moynihan: That was a conversation with Indian psychiatrist and authority on evidence, Professor Prathap Tharyan, speaking to me, Ray Moynihan, on The Recommended Dose from Vellore, India. Thanks so much to our tenacious producer Shauna Hurley, to Jans Muths for editing, to you for listening and for recommending "The Dose" to others.
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