Looking at diseases with new eyes

"Dr Noshir Hormusji Wadia is a role model for physi­cians and his evolution as a master clinician neurolo­gist extraordinary of India has charted a course which young aspirants choose to follow... Thousands of neuro­logical patients have sought his advice and he has served them with a god-given touch of compassion re­gardless of their social status,” reads the citation to the first Rameshwardas Birla National Award (1999) for an outstanding clinician practicing modern medicine. The presentation at the hands of Dr Hari Gautam, chair­man of the University Grants Commission was organized by the Bombay Hospital Trust’s board of management at their S. P. Jain Auditorium on August 4, 2001.

In his acceptance speech Wadia counted his bless­ings with humble nonchalance, "A caring doctor is amongst the privileged few who gets paid to do what he enjoys doing most, whilst millions strive simply and even boringly to earn their daily bread.”

The J. J. Hospital and Grant Medical College’s consultant neurologist for life (a gazetted designation formulated for him by the Government of Maharashtra when he retired from active duty there as honorary doctor and tutor earning Rs 250 per month at the end of 25 years of service in 1982), Wadia continues as direc­tor of the department of neurology at Bombay’s Jaslok Hospital and Research Centre.

He has garnered sheaves of honor in 45 years of service to his profession and society including the conferment of the doctor of science, honoris causa by the Benaras Hindu University in March 2000. Its cita­tion notes that the "internationally acknowledged” Wadia, president of the Neurological Society of India (1963-64) and founder member of the Epilepsy Associa­tion of India, "is the only Indian to have the distinc­tion of being elected as first vice president of the World Federation of Neurology.” The award presented by All Physicians of Maharashtra State at MAPICON 2001 notes: "You turned each obstacle into opportunity for us with your extraordinary brilliance and unmatched wisdom... Your knowledge has no bounds. Your humility has no limits. You have left an indelible mark on our hearts... With a deep sense of gratitude we remember you as our wonderful teacher and seek your blessings for ever.”

Wadia is currently president and chancellor of Sree Chitra Tirunal Institute of Medical Sciences and Technology in Kerala. "Serendipity has strange ways to bring men and ideas together for a good cause,” he writes in the Institute’s silver jubilee souvenir about to be published as Silver Lines. Initially restricted to two major specialties — medical and surgical neu­rology and cardiology — the Institute was the progeny of Maharaja Sree Chitra Tirunal, of the erstwhile state of Travancore, C. Achuta Menon, the sagacious chief minister of Kerala and the government of India which placed it under the ministry of science and technology (not health) to provide high grade service, education and research in medicine and biotechnology and to innovate new medical devices. A third wing, started shortly after inception for health sciences studies, conducts research and training in public health, epide­miology, biostatistics, etc.

Run by an independent body of reputable men from all walks of life, it was mandated that the president of the 26-acre Institute be an individual of high public repute and integrity without political affilia­tions, notes the Silver Lines article. Wadia has suc­ceeded G. Parthasarathi, India’s former permanent representative at the UN, and jurist Nani Palkhivala in that honored post after serving on the Institute’s governing bodies for over 20 years. Recognized as an "Institute of national importance” and a deemed uni­versity, the Institute offers 21 degree and diploma courses including speciality nursing. The constantly expanding facilities are provided free of charge to the poor and at half or less than half rates to low income groups. Only about 20 percent of patients pay the full charge for the expert medical care but no special rooms or services are provided to them, notes Wadia.

Silver-grey serenity envelopes the short, slightly thick-set man smiling benignly at our confusion over neurological nomenclatures as he speaks of the three-fold evolution of his medical skills — as healer, teacher and researcher. Referring to the treatment of patients as a doctor’s primary duty, Wadia describes "the joy you feel, the inner satisfaction, when a patient gets well. It is amazing how people react to you in India. The emotional attachment to a doctor which we have here is very rewarding and not comparable in any other part of the world!”

Equally important to Wadia is teaching. If you have not "passed on the knowledge painfully acquired... you have not carried out your mission in life,” he de­clares, viewing in his mind’s eye the generations of students now "making their name all over the world.” It is a mission he has inherited from his "heroes” Dr Minocher Mody and Dr R. V. Sathe during his undergradu­ate years at the Grant Medical College, from Sir Russel Brain and Dr Douglas McAlpine, surgeon Dr G. Rowbotham and Dr Ronald Henson during five years of neurology apprenticeship in the UK. All these dedicated men performed miracles with clinical insight and human compassion when the "CT (scan) and MRI and much else had not been born, when all we could do to make a (neurological) diagnosis was to put a little air into the brain, record EEGs and perform myelograms with oily dyes... McAlpine was a superb bedside teacher and it is to him that I owe much of whatever ability I have to teach (as also to Prof Kothari who enlivened chemistry by his lectures at Bombay’s St Xavier’s College),” acknowledges Wadia in his "Autobiographical musings” published in the Evolution of Neurosciences in India — Biographical Sketches of some Indian Neuroscientists edited by Prof K. Rajasekharan Nair.

"Minocher was a fantastic physician,” says Wadia who closely observed the benign Mody as a student even though he did not have the opportunity to work as a resident under him: "His whole approach, demeanor was sympathetic. I learnt a lot from him. He never did research but he looked after his patients and taught superbly!”

Of Brain, an international authority on neurology "whose book I had read many times through long hours of postgraduate study,” Wadia notes, "(He) was a big man in every way. He had published the first edition of his book a little before he reached his 40th year. It was an instant success. He was the president of the Royal College of Physicians then, chairman of a Royal Commis­sion, member of many national and international commit­tees, editor of Brain, etc. He was consulted by pa­tients, often high and mighty, from home and abroad, including Winston Churchill, but he showed equal con­cern for his NHS (National Health Scheme) patients in the hospital wards. Despite all his commitments, he read voraciously and wrote profusely on a variety of divergent topics... He was a quiet man of few words, appearing pompous and remote to those who did not like or know him, but really a shy, concerned, unassuming man. He never talked about himself or his achievements which were many. He could cope with his enormous load of work and commitments by being thoroughly organized, punctual and to the point. For example, when we resi­dents wanted to talk to him about ourselves, we had to ring his secretary, Ms Marwood, for an appointment. He would come the next day with a smile and say, ‘Ms Marwood says I have to talk to you for 15 minutes.’ This is how he saved or I should say shared his person­al time. To some, this would appear superficial and pompous, discourteous or even ridiculous, but to those of us who knew him and worked with him it was quality time. In 15 minutes he would grasp our problem (whether in research, career development, personal, etc), give a solution and promise to help if he could. And he was as good as his word.”

The great human beings that his mentors were seem to have led Wadia to consciously cast himself into a similar mold. His Indian teachers said, "chaal, (neu­rology department) shuru kar (come and start).” He recalls the enthralling 1950s when a newly independent India was embarking on a journey of modernization, "the heady days... of Jawaharlal Nehru with his ‘promises to keep,’” that made the neo-scientist itch to return home to partake in the joyous task. "There was no desire to stay back,” he writes, adding, "Sadly, those invigorat­ing days are no more for the young... Now the rules, the red tape don’t let effective people give of their best,” he rues.

When Wadia joined the J. J. Group of Hospitals as an assistant honorary neurologist under Dr Menino D’Souza he was the first in the field except for Dr Eddie Bharucha at the King Edward Memorial Hospital. However, "The contrast with London was stark. There was a somewhat unbridgeable time, vision and sound gap.” His London students had been confident and outgoing. The J. J. lot were shy, uncertain and tongue-tied. He recalls other contrasts: "I had been used to a secre­tary, a dictaphone, a large neurology library, a medi­cal records department which produced back records of 30 years in a few hours and OPD by appointments. Back home there were no special neurology beds, no records worth their name, open walk-in-out patients, notes were what you wrote and not dictated, and an old irreparable EEG machine. It took some adjustments, but after some moments of uncertainty and hesitation, I decided to meet the challenge and plunged into the uncharted waters of Indian neurology. There was no going back.” But all in all, "it was an exciting time with things taking shape despite many handicaps,” under the vision­ary guidance and support of the doyen of surgery Dr Shantilal Mehta who was the J. J.’s medical superinten­dent. The neurology department expanded briskly from six to 100 beds within four hectic years. Alas, politi­cal interference led Mehta to resign in the early 1960s and to be replaced by a bureaucrat from Baroda who refused to grant Wadia any further facilities with the words, "There is no milk for patients in Baroda, and you want more x-ray plates!”

The third ray of the Wadia prism reveals the academic man. Though not a laboratory trained re­searchist, Wadia’s ability to look at diseases with new eyes led him to realize that disease in India differed from its manifestations in Europe and England. Not only do environment and genes change the pattern, there is still much infection abounding in India which has been rooted out in England. "In India when you treat brain tumors you think of TB tumors” which can now be medi­cally treated unlike gliomas, common in the west, which are cancerous and require surgery. Wadia was the first to realize the tubercular origin of these tumors which are found in abundance in India but had not been seen by him during his years in UK hospitals and in those initial years even tubercular tumors had to be operat­ed.

Another Wadia observation was that multiple scle­rosis which is so common in northern Europe has a very low incidence in India with the exception of Parsis. He quotes its all-India prevalence at 0.5 to 2.0 per 100,000 as against 24-30 per 100,000 among Parsis. He conjectures that Parsi genes make them prone to the disease as the climate and environment are common factors to both populations.

The early 1970s had seen an epidemic of conjunc­tivitis. At that time there had also been manifesta­tions of polio-like disease among adults and Wadia says he found that each of these adult polio patients had had the "red eye” disease. "Four to five months after the conjunctivitis epidemic abated the neurological polio-like disease (also) disappeared,” recalls Wadia. The conjunctivitis pandemic had spread from Ghana to Japan affecting millions in its wake, Wadia informs us. The virus was identified by Japanese virologists, and Wadia forwarded to them the refrigerated sera of his patients. They matched the Japanese specimens. In 1981 when the epidemic came back of India, Wadia says he collected 581 patients who had the viral infection which entered through the eyes to produce polio-like disease in adults. His astuteness won Wadia the fellow­ship of the Indian Science Academy which is among his prized possessions.

A founder member of the Multiple Sclerosis Society of India, the Cerebral Palsy Association of India and the Muscular Dystrophy Society, Wadia says he encourag­es his students to do likewise, help patients and their relatives, spend time with them, help them raise funds through contacts. "The doctor must do this to give something back to society,” he believes.

The field of ataxia also bears the Wadia imprint. A disorder of the small brain or cerebellum which shrinks or degenerates, ataxia affects several members of the family through generations. It manifests itself in a drunken gait and speech, the patient becoming bedridden over time, says Wadia. The first of this group of diseases was originally identified by a German in 1861 but working in the 1960s Wadia noticed his Indian patients (Parsis excepted) also displayed very slow eye movements. It was first described by Wadia and his colleagues and proved in post mortems in collabora­tion with British scientists. Unfortunately, genetics not having been developed in India, the credit for the discovery of the relevant gene went to a scientist in Cuba.

Parsis are more susceptible to strokes, paralysis, Parkinsonism and Alzhei­mer’s disease, says Wadia, "because we live too long.” Primary neurological cases in the community are rare, he notes, adding that when one surfaces at the B. D. Petit Parsee General Hospital (PGH) he transfers the patient to the Jaslok Hospital as a separate neurological department at the PGH is not warranted, given such few patients.

The son of Hormusji and Dinamai, Wadia was born in Surat in 1925 and was still studying when his father died. Unfazed, his elder brothers Jal and Jimmy sol­diered on with the family’s timber business to give young Noshir the opportunity to finish his vocational education. Married to Dr Piroja (née Irani) a clinical neurophysiologist who joined their speciality team at the J. J. and thereafter at Jaslok, Wadia’s affection includes her two sons Ruiynton and Kaikhushru from her previous marriage. Both are now established chartered accountants and bankers and the four grand children complete the Wadia family.

Formerly an active sportsman (Wadia refers to his cricketing forays that strengthened the professional team spirit in his autobiographical musings) Wadia is now content to watch the sports channels on TV, savor the pleasure of his garden in Khandala. The shared joy of classical music, both Western and Indian, is an additional bond between Wadia and his wife.

While Wadia says he would prefer the children to marry within the community he concedes that "many circumstances today lead them to seek partners outside the community,” adding, "I don’t think one should fight and destroy their life. I am not so sure that we have such happy unions within the community that once married out, they should be ostracized.” He goes to the next logical step and asks why out-married women, who "wear the sudreh and kusti, continue their Zoroastrian prayers even better than many of us,” should not have the privilege of raising their children as Zoroastrians?

Very proud of their religion — neither Wadia nor Piroja would like it to change or die out — they nonetheless believe it is "wrong” that a dead man’s non-Zoroastrian wife of long standing is made to sit out and not attend the prayers.

"If I die, I’ll go to Doongerwadi,” asserts Wadia, adding, "(It’s) the natural thing, done over genera­tions. But there is room for an alternate mode of disposal of the dead.” The original disposal of the dead in Iran must have been functional, reasons Wadia. He also notes that there are any number of places in the world without dakhmas. "Do souls in UK or USA not go to heaven?”

Expressing personal doubts about the practicality of breeding vultures at Doongerwadi Wadia says, "Cir­cum­stan­ces are leading us to accept change... reality is pointing elsewhere. We shouldn’t drive people away from the religion. We are too small a community to become so pedantic!”

Neurological nuances

At Parsiana’s request Wadia differentiates between the two common types of dementia. When neurons (or nerve cells) degenerate, it is called Alzheimer’s disease. When a series of small strokes interfere with blood supply to the brain it is termed vascular dementia. Diabetes, old age and smoking could also contribute to the latter. New drug therapy has been created for the treatment of Alzheimer’s, says Wadia but the snag is to differentiate between normal aging with memory lapses and early Alzheimer’s, wherein the doctors are depend­ent on diagnostic technology like the MRI scanner and SPECT.

Wadia is liberal with his time to educate Parsiana and its readers in the various hi-fi equipments that probe our mental health:

•the EEG or the electric encephalogram studies the electricity of the brain. It is invaluable in the diagnosis and treatment of epilepsy which results from the disturbance of the brain’s electric charges.

•The MRI scanner records the structure of the brain, pinpointing changes or tumors.

•SPECT measures the activity of the neurons which extract the necessary glucose and oxygen from the blood flowing through the brain. If the neurons are dying, the brain does not extract these agents and this is recorded by SPECT.