Sunday, November 9, 2008

What to do?

Though forty five minutes on the back of a motorcycle sitting sidesaddle in my sequined skirt and sparkly sandals would seem like a long ride to some, it was not nearly long enough for me to complete a list in my head of all the ways I could have been startled, nudged or bounced off the back of the vehicle into oncoming traffic without Ganesh noticing. I primly clutched a book on my lap and planted my slippered feet on one foot peg in such a way as to keep from absentmindedly slipping a shoe into the spokes as we sped along a road that was sometimes suitable for highway speeds and sometimes fit for only donkey carts and barefoot pedestrians. This is how it’s done in India after all and I gazed at the women perched lightly behind their husbands in their perfectly pleated saris as they sped passed Ganesh and me. I slithered one arm like a meat hook around his waist at least secure in the knowledge that he is one solid hunk of human being and that even if I were flapping behind him like a windsock, he would barely budge.

In consideration of my lack of expertise here, he refrained from his normal speeds if only to keep me from yelling “Jesus Christ!” in his ear again since it just makes keeping us upright that much harder for him. A Hindu, I’m not sure he recognized my outbursts as blasphemous as much as he feared I was one of those missionary types trying to convert him to Christianity at vulnerable moments when death looked certain. The first time I did it, he made it clear that he found it startling though I’m not sure how the Land Rover pressing its front grill against my person didn’t startle him more. This was a time in which I felt a gentle tap on the shoulder followed by a whispered, “um, pardon me . . .“ didn’t capture the urgency. But this is India where the motto ‘adapt’ is sometimes a gentle reminder to be peaceful and sometimes a virtual court order so I resigned myself to tolerate the Land Rover until actual blood was spilled.

If Ganesh had thought this was going to be an ordinary trip to Tamil Nadu he learned otherwise the moment I landed on the seat behind him. Not always the daintiest of creatures, I pole vaulted off his shoulder onto the motorcycle and deflating both Ganesh and his back tire simultaneously as I landed. “What?” I asked when I saw his look of astonishment, “Where’d you jump from?!?” he asked, “Beside me stood a cat and then on my seat lands an elly-fant!” No long journey with a woman is likely to go well when you’ve started it by calling her an elephant. “What do you weigh?!?” I refused to answer and just stared silently at the spot on his back that when punched hard enough, would bruise his spleen.

Of course I had forgotten about his more vulnerable organs by the time we arrived simply because I was happy to be alive. I sauntered into the restaurant and slid into a booth like I was a regular though it was obvious when everybody stopped what they were doing and stared that I was not. Not many white people arrive at this particular village at this particular restaurant for any particular reason.

As Ganesh got up to wash his hands, the waiter handed me a glass of tap water. I could feel the grit of the road in my teeth and as I pondered whether or not my stomach could handle the local bacterial brew, I noticed that Ganesh was standing inside a small stall with two sinks and I thought, ‘please, please tell me that’s not the bathroom.’

Now I realize in a country that smells this bad and is populated with this many people, privacy is a luxury. And in Ayurvedic medicine, practitioners warn against the dangers of holding back any natural bodily function which then leads to certain brashness that American’s aren’t accustomed to. I constantly see signs all over Bangalore that kindly ask its residents not to pass urine on the street and I constantly step over the signs that they’re doing it anyway. I couldn’t help but ask Ganesh one day why it is that whenever an Indian man is standing still it’s because he’s peeing. I don’t think he had an answer or even understood the question since, in his mind, it sounded rhetorical. A recent acquaintance recently pointed out that all of the signs are in English only which sparks a whole new set of questions.

So as I sat poised to drink my water, I had to wonder if I was setting myself up for the worst sort of karaoke experience of which I personally would never recover. My internal debate was put on hold when Ganesh returned and gestured towards the sink, “go wash your hands,” he instructed and I scampered up to rush towards the sink before the American in me could instinctually respond to his demand with a defiant “hey . . . !” regardless of the fact that not washing my hands when ordered was only going to put me in greater bacterial peril. As I stepped in front of the sink, I noted that there were no signs of an actual toilet much to my relief but it still left me wondering, public debut aside, if I would be able to tolerate the tap water. On the one hand, simple precautions are important but on the other hand have I wussified my immune system? What good are biceps if it’s my immune system that buckles?

In a recent Healthlink post Subra Kugathasan, MD, Medical College of Wisconsin Associate Professor of Pediatrics (Gastroenterology) said, "The immune system is there for a reason. It's there to recognize 'the bad guys.' The immune system allows your body to kill those bad guys and allows you to survive. In order to harden the immune system, the immune system requests some kind of stimuli all the time." That doesn’t mean bottoms up on tap water all over India, however. And watching Ganesh wipe his plate with a napkin before serving lunch didn’t convince me I wasn’t dining on microbial appetizers as it was. A paper napkin is probably as effective as ordering pathogens away with an ‘allakazam!’ which I considered doing simply to entertain the patrons who were still staring in spite of the fact that it sounded a little too much like a Muslim blessing in an area where I couldn’t gauge religious fervor.

Ultimately the problem with contaminated water is that nobody knows the recipe. In the book ‘Plague Time,’ Paul W. Ewald, professor of biology at Amherst College, argues that long-term infections may be at the root of chronic diseases including cancer so that any immediate digestive distress may be the least of my concerns putting aside for the moment the benefit of a hardened immune system. As an example, T-cell Leukemia which results from a cancerous growth of white blood cells develops from an early infection, “This cancer has been especially well studied in Japan, where people who die from it are infected as babies from their mothers’ milk. Though infected during the first year of life, they first develop leukemia many decades later – about half the people who eventually develop the cancer do so after their sixtieth birthday. Only about one out of every twenty-five infected people develops the cancer,” Ewald reports.

The deciding factor in the leukemia lottery is anybody’s guess since lifestyle factors are so broad it would be impossible to say. Some scientists though will just say anyway. In research that appeared in ‘the China Study’ where Aflotoxin was used as a starter fuel for liver cancer, T. Colin Campbell blamed the end results on protein intake. The protein in question that seemed to accelerate tumor growth was casein, a dairy protein, but Campbell made the assumption that all proteins would do the same even though he had no specific evidence. Since Aflotoxin is a mold that grows on peanuts and more often than not contaminates peanut butter as a result, it can be assumed that every American child including me who grew up on peanut butter and jelly sandwiches and a glass of cold milk is at risk. At that age, I may still have opted for a potentially damaged liver because frankly peanut butter is yummy and nothing can unstick it from the roof of your mouth quite like milk.

And much like the case of leukemia, the sweet mother who lovingly served the peanut butter sandwiches and milk, may have already gifted other germs that can sneak up later. As reported by Ewald a schizophrenia expert named Fuller Torrey found that nearly half of the schizophrenics tested by his group were infected with toxoplasma gondii. This further supported a study published many years earlier that tested schizophrenics for both the existence of LSD and T. gondii infection, “Over half of their patients were infected with T. gondii, and these infected patients were almost always the same patients who tested positive in the LSD test. The production of LSD or an LSD-like compound in T. gondii-infected schizophrenics strengthens the case for T. gondii as a cause of the hallucinations experienced by schizophrenics, and, more generally, as a cause of schizophrenia.” Since the mothers of schizophrenics were almost five times more likely to be infected, scientists suspect transmission during pregnancy. The only other means of transmission discussed was through the licking of cat droppings which I suspect is far less likely barring unfortunate unsupervised sandbox incidences since cats see a child’s sandbox as luxury accommodations.

Given those risks, it’s almost understandable that the western approach is to Clorox the crap out of everything which interestingly seems to mirror our foreign policy. Theoretically however this leads to an immune system imbalance as well as an exaggerated reaction to simple allergens which can develop into life-threatening asthmatic attacks as well as autoimmune disorders. “Exposure to microbes, through active infection or in the absence of infection, may initiate protective responses.[5] In the absence of infection, both viable and nonviable components or fragments of a broad range of micro-organisms found at different concentrations in different environments may be involved. These microbial derivatives, which are primarily recognized by the innate immune system (as opposed to T-cell-specific adaptive immunity), may drive protective responses, especially at the cytokine level. This exposure to microbial derivatives may play a critical role in the shaping of the immune response when encountered at important stages during the maturation of immune responses. This could result in the development of immune tolerance to potential allergens” reported a recent post on Medscape entitled ‘The Hygiene Hypothesis Revisited: Pros and Cons’ by Erwin W. Gelfand, MD National Jewish Medical and Research Center.

"Think about countries in Africa like Gambia, a country that has been studied very well . Ninety to ninety-nine percent of people in Gambia have intestinal worms at some point in their lives. But the chronic immune diseases like asthma, Crohn's disease, or multiple sclerosis are not heard of, never even mentioned in their life. They don't know anything about such diseases in those countries. While one may argue that maybe their population is genetically not predisposed to these diseases, other factors appear to be in play,” said Dr. Kugathasan.

The Medscape piece explains this concept in greater detail by saying, “A major basis for the hypothesis is that improved hygienic conditions in Western or developed countries results in less infection-driven or microbial pressure during early but critical time periods in early childhood. This change in pressure, in turn, results in an important failure to maintain an optimal balance between the 2 opposing T-helper cell responses when cytokine profiles are examined -- the Th1 and Th2 responses. Th1 responses are dominated by interferon (IFN)-gamma and interleukin (IL)-12 production, whereas Th2 responses are primarily associated with IL-4, IL-5, IL-13 (and IL-10) production. In association with reductions or altered exposures to infectious agents or their components, it is proposed that Th2 immunity, predominating from birth, dominates through critical childhood periods, resulting in the higher incidence of atopy and asthma.”

According to The National Heart, Lung, and Blood Institute as reported in ‘Modern Hygiene’s Dirty Tricks, the Clean Life May Throw Off a Delicate balance in the immune system’ by Siri Carpenter for that incidences of asthma are now 1.75 times what it was in 1980 in the United States, and for children less than 4 years old, 2.60 times the earlier incidences.

As I’ve often mentioned, I have suffered from bouts of asthma, mostly sports induced, as well as dermatitis. Both of these conditions can be controlled by keeping my carbohydrate consumption down and omitting grains from my diet completely. My experience so far in India is that my asthma has disappeared completely in spite of heavy air pollution and my dermatitis is controlled regardless of my diet which has suffered as I’ve navigated a city addicted to sugar in all its forms. Is this proof? Certainly not. As in all other ‘studies’, there have been too many lifestyle changes confounding the results. In Bangalore I sleep more, work less, train reasonably and have far less stress. And though I’ve certainly had occasion to challenge my immune system, had I not been inoculated by order of my Dad before I arrived, I’d be at risk for polio, malaria, typhoid and Hepatitis. Interestingly, inoculations themselves decreased the severity of allergic reactions in some children cited while again other scientists argue that low-level infection or exposure to the actual virus provides greater benefit in the long run.

“Several studies have advanced the theory that fecal contamination of the environment (and possibly infections such as hepatitis A), and unhygienic food handling may similarly protect against development of atopy. Intestinal microflora could also exert a continuous stimulation of the immune system, resulting in immune polarization -- the cleaner the intestine or the nature of colonization of the intestine, the more Th2-driven is the immune response,” wrote Gelfand. Fecal contamination? Unhygienic food handling? Check! and check! This is India. If food regulations exist here they’d be followed as strictly and enforced as reliably as the traffic laws.

I followed Ganesh recently on a little adventure south of the city to find an apartment to rent. A client had told him about a newly constructed building where there where flats available and I went with him to check out a neighborhood I hadn’t yet explored. As the highway turned to a dirt track and we started maneuvering the motorcycle around not only the usual pack of stray dogs but families of squealing piglets and a more forthright collection of cattle that were less willing to yield than their downtown brethren, I began to wonder if I was about to be the victim of a ransom scheme. Bandicoots! “Ganesh, did you tell anyone you’d be traveling with a white woman?! I don’t have money, you know!” I yelled at the back of his helmet. When we stopped at a stall to wait for his client, he ordered the most suspect baked item I have ever seen. It had a creamy topping that sat sweating and melting beneath a sun that blazed through the bakery case. It was specked with an equal number of Technicolor candied fruit shavings and common house flies and tossed to him on a corner of newspaper by the same ungloved hand that gave him his change.

Even after he all but ordered me to taste it and/or select a snack of my own, I refused as I pondered what it would take to wrestle an item away from the fly infestation. I pictured walking a plank with Ganesh nudging me unkindly from behind. Hold on there little grumbly belly, mummy isn’t going to hurt you, I whispered soothingly to my empty stomach after again refusing in a tone that made Ganesh look around at the other patrons. Though I’ve had occasion to imagine a number of creative ways to fell Ganesh, he was as usual unfazed by his medicinal dosing of microbes or my foot-stomping feistiness.

"What has happened now, with globalization and human migration, people move to areas that are very, very clean. Within one generation we have moved into a different environment. What we have been finding out is that in the second generation of Asian, Latin American and African children, where the first generation had been exposed to those kinds of parasites and early childhood infections, the second generation that has moved to 'cleaner' countries has not been exposed. The incidence of Crohn's disease, multiple sclerosis, and chronic asthma is as common in the second generation from the third world as in those with European or North American backgrounds, and in some cases even higher," said Dr. Kugathasan and I couldn’t help but wonder what happens when you’re unwise enough to migrate in the other direction.

My mother was a first generation American born of a Sicilian mother and a Swedish father. Before dying at the age of 61, she suffered from rheumatoid arthritis and Type 2 Diabetes in spite of her often below-average bodyweight. My sister, my nephews and I have all had digestive issues throughout our lives. My father is essentially bulletproof and, of the few maladies he complains of, none of them occur from anything other than bad habits completely of his making and often questionable lifestyle choices which make him marginally unhealthy but very entertaining at parties.

While my mother spent most of her childhood in Catholic School, my father spent his youth on farms during extended summer vacations and as a result chose to raise us part of the time on a farm of his own where he grew much of our food. As it turns out, it’s exposure to livestock that helps cultivate the immune system. In fact, Jared Diamond argued that point even within the very title of his book ‘Guns, Germs and Steel’ in explaining what factors lead to the dominance of one society over another.

“The protective effects of a farming environment in childhood provide important evidence in favor of the hypothesis that environmental factors encountered in childhood could have a lifelong protective effect against the development of allergy. Since there are numerous reports of an increase in asthma in a number of settings -- for example, urban African towns and inner cities in the United States, it is not simply a clean vs. dirty environment that may dictate outcome. The farming environments may be creating an immunologic setting, beyond endotoxin exposure, that directs the immune response along a particular pathway,” wrote Gelfand. In the case of my sister and me, our health problems developed later and our time on the farm was limited to weekends and perhaps cancelled out entirely by my mother’s efforts to love us to death with sugar.

Though I now live in a city, I have regular contact with livestock whether I know it or not. The cows and donkey carts that regularly merge with downtown traffic are the more obvious signs of an inner-city animal population but the other morning I saw the spindly legs of goats being carted to market in the same Rikshaws I take to work. Though the two goats sat quietly with their owner as if this was their regular mode of transportation, I’m guessing they make the trip to Russell Market only once. I make the trip to Russell Market more frequently where I mingle with the chickens, cows and goats as I weave between the vegetable stalls in my flip flops. Even the eggs I bring back are never washed and are often smudged with broken egg yolks and what I’ll call ‘dirt’. My belly has never felt better.

It’s the hearty constitution of farmers that had researchers at the University of Iowa in Iowa City pondering parasites. Joel V. Weinstock, David E. Elliott, and Robert W. Summers are examining the possibility that immune imbalances may contribute to the rising incidence of inflammatory bowel disease reported Carpenter for

“Weinstock's group proposes that the Th1 dominance stems from a lack of parasitic worms called helminths. Despite parasites' bad reputation, the researchers contend that helminths are important members of the intestinal community. Throughout evolution, they say, the human immune system has grown to depend on helminths to suppress overly aggressive Th1 responses to bacteria, viruses, and dietary proteins. Because modern sanitation has largely eliminated intestinal parasites, the immune system sometimes begins to attack the lining of the gut.”
The article goes on to say, “The team has also begun treating a few patients suffering from inflammatory bowel disease by giving them a drink spiked with eggs from a harmless whipworm. Of six patients studied so far, all showed substantial improvement in their symptoms, the researchers reported at the May meeting.” I think I’ve had that drink. Here we like to call it ‘tap water’.