|Year : 1991 | Volume
| Issue : 3 | Page : 140-146
Remembrances of things past
Sohan Singh Hayreh
Department of Ophthalmology, College of Medicine, University of Iowa
Sohan Singh Hayreh
Department of Ophthalmology, College of Medicine, University of Iowa
Source of Support: None, Conflict of Interest: None
The author relates an unlikely journey from his rural village in India, through medical school, a prestigious fellowship with Sir Stewart Duke-Elder, and a colourful career in the United Kingdom and the U.S.A., as a clinician and researcher, particularly in the area of vascular disease of the eye and optic nerve.
Keywords: Hayreh, Sohan S. history
|How to cite this article:|
Hayreh SS. Remembrances of things past. Indian J Ophthalmol 1991;39:140-6
I was born in 1927 in Littran, an obscure village of some 10,000 souls, in the Punjab, the rich, fertile farming area, which at that time was a large state covering much of Northwest India and half of what is now Pakistan. I lived in this very stable community, attended Elementary School there and Middle School in a larger village nearby, and graduated from the nearest High School, in a town about four miles from my village. The entire village was virtually an extended family; all the farmland around the village (and it was divided into very small holdings of 5-10 acres) was owned by people named Hayreh-all of the Sikh religion and descendants of the one farming family which had settled there over a millennium before. Historically, we are the offspring of the Aryans who moved out of Central Asia (now Turkey) about 6th-5th millennium BC, and finally settled in the Punjab in the early second millennium BC. (Hilter's concept of the Aryans was totally wrong!)
In agricultural communities in India 50-70 years ago, very few children went to school; literacy was not essential for the traditional life, and most children helped their parents from an early age, the girls with the household chores, and the boys in the fields. My father, in the early 1920s, was one of the first half-dozen boys from Littran ever to go through High School. I was one of the first 2 or 3 who went to University - and I was the first person from my village ever to become a physican. There was no High School or College Counselor, advisor or anyone to give guidance about careers, the most educated young Indians of that time drifted into the office jobs available under the British administration. I became a physican because my Mother decided - unilaterally - that I was to be one, mostly because at that time there was no physican in the village, and no medical help was available when she or one of us children was ill. this was in spite of the fact that she had little idea what a Western physician did, or how expensive and lengthy the training was. Like all countrywomen of her generation in India, she had never been to school, but she was intelligent and determined.
To become a physican, one had to choose the required subjects at age 14, and apply for the pre-medical course for two years at University after finishing High School. In the early forties there were only two medical colleges in the whole British Northwestern India (What is now Northwestern India west of Delhi and Pakistan). Of a total of about 150 students admitted yearly by those two colleges, half were nominated by Politicians (as in the American Military Academies), while those who had no political connections had to complete for the other half. These were awarded according to the results of the premedical examination, except that the numbers admitted had to be proportionate to the number of Muslims, Hindus and sikhs in the population. Hence, out of thousands of Sikh students who passed the premedical examination from northwestern India, only about the top 25 students would be admitted to the two medical colleges. I still wonder sometimes how I, the country boy from Littran, was admitted to one of the oldest and most prestigious medical colleges in India: King Edward Medical College Lahore.
Unfortunately, my enjoyment of this privilege was short-lived. I started my medical education in 1946, and in August 1947, there took place the partition of India, a human tragedy of enormous dismensions for the entire population of Northwestern British India. There were bloody communal riots between Muslims and non-Muslims, massacres of about 500,000 men, women and children, and mass migration of about 5.5 million [3 ]first of Hindus and Sikhs from what is now Pakistan to India, then reprisals and the same horrors and mass eviction of Muslims from the Indian territory adjacent to Pakistan. It all started in Lahore, which was the captial of the Punjab, and we medical students saw much of the tragedy happening. Lahore went to Pakistan, and and King Edward Medical College with it. So I and all the other non-Musilm medical students had to get out as fast as we could. We had to be squeezed into the only Medical College in the Indian part of the Punjab after partition - at Amritsar, which was a big refugee center, being only 16 miles from the Indo-Pakistan border, and its main bazaar was totally burnt. The rest of my undergraduate medical career was much less eventful, and I received the degree of Bachelor of Medicine and Bachelor of Surgery (equivalent to M.D. in the U.S) in 1951 [Figure - 1]
I started my residency in Surgery in my alma mater (Fiq 2) My family at that time was in a state of dire financial disaster. My father, along with thousands of other servicemen from the state of Patiala was given compulsory early retirement, because the princely states in India were dissolved. His pension was inadequate to support a couple, and there were no job available. I had two younger brother and two younger sister still at school. I wanted to pursue an academic and research career, but I could not abandon my family, and there were no academic job opportunities available which would support a family. For junior physicians, the only jobs that paid a decent salary were in the Indian Army, and so 1, with many of my fellow graduates, joined the Army on a short service commission. I was not a good solider - I loathe regimentation and deferring to people who happen to have superior rank for reasons other than intellectual capability. Morever, I spent most of my service in rough field conditions near the Pakistan border [Figure - 3]. I hated every minitue of my Army service, except for the handsome pay which was helping to keep our family going. I got out of the army as soon as I finished my contract.
In the meantime, a new medical college had opened in Patiala, Punjab, and I obtained the only position still open, the lowest form of faculty life the Anatomy Department. To find a topic for research, I talked to the Director of Medical Education in the punjab, who had been my professor of Ophthalmology. He had recently seen two papers in the British Journal of Ophthalmology by Jules Franqois and his colleagues
, on vascularization of the optic pathway, and suggested that I might look at those. I was intrigued by the concept of the central artery of the optic nerve put forward in those papers. There was no one around who kenw anything worthwhile about serious scientific research and could guide me, and no research funds were available, so I was my own investigator, technician and director of research, without any prior training whatsoever. I had to learn everything the hard way. In India I could not find any material to prepare vascular casts to study the anatomy of the vascular bed in the human. I did serial histological sectioning and staining myself because there was simply no technical help. I discovered from the literature that the Du Pont Company in Delaware supplied liquid latex for preparing vascular casts, but I had no research money to pay for it, and my salary at that state was only about $20 a month! Even if I had had money, the Government of India did not allow Indians to buy goods from abroad, which would have to be paid for in hard currency. With the faintest of faint hopes, I wrote to the Du Pont company, asking if they could possibly send me some free sample of liquid latex, and they sent me two gallons, which was enough for my project. The rest, as they say, is history. The orginal object of my study was to prove the existence of the central artery of the optic nerve, claimed by Francois et al, but I ended up proving that the artery did not exist and investigating the entire vascular bed of the orbit, optic nerve and the eye in detail. The central retinal artery component of my work was accepted as my thesis for the Master of Surgery (equivalent to the American Board) by the Punjab University.
Once in a while there is an even in life which turns out to be crucial in determining one's entire future. For me that event came after I had finished the
anatomical studies of the vascular bed of the eye, optic nerve, and orbit: I found the question of the pathogenesis of optic disc edema in raised intracranial pressure a fascinating field, and wanted to go on to investigate that, but there were neither facilities nor fnds available for me to do so in India. It seemed that my career in ophthalmic research had come to a dead end. Then one day, in a newspaper, I read a small announcement by the Beit Memorial Trust in London about fellowships in medical research. I wrote for more information, and received with the application form a brochure containing names and brief biographies of 300 Fellows of the previous 50 years or so of the Trust. That list was very discouraging, because it included many famous names in twentieth-century medical research, and three Nobel laureates (perhaps one of the objectives of sending the list was to deter unqualified applicants!) The other intimidating aspect of the Fellowship, for a lonely researcher sitting in a small city in India, with very little selfesteem and no research guidance, was the Trust's requirement that the candidate submit his own detailed research plan and a letter from a research director in Britain giving approval of the plan of research and agreement to accommodate the candidate in his laboratory, if the candidate obtained the Beit Fellowship. Neither I nor anyone I was acquainted with knew anyone prominent in British ophthalmology. After a great deal of soulsearching, I decided to go straight to the top. I wrote to Sir Stewart Duke-Elder, the Director of the Insititue of Ophthalmology in the University of London and doyen of British ophthalmology, sending him my research plan on the pathogenesis of optic dis edema in raised intracranial pressure. To my amazement he replied, approving my research project and agreeing to take me if I recived the Beit Fellowship. So I applied for the Fellowship, knowing that since the Fellowship was for any branch of medical sceicnces and such a highly prestigious one, I stood almost no chance, but it was the only chance I had. My pessimism was made worse by a very famous British Professor, an international authority in Internal Medicine and a past Beit Fellow, who happened to be passing through Patiala. On hearing that I had applied, the professor remarked, "No one from India should aspire to a Beit Fellowship." At that, I lost all hope. Nevertheless, in June, 1961, I got the most important letter of my life - from the Beit Trust, informing me that I was one of the five Fellows elected that year, funded to do medical research for three years. I remember that letter sent me into something near a state of shcok; I had succeeded beyond my wildest dreams.
I arrived at the Institute of Ophthalmology in London in October, 1961, as a Beit Research Fellow. On my first day, very nervous, I went to see Sir Stewart Duke-Elder and gave him my detailed research protocol. He glanced through it and looked at me with a smile, then asked me, "How old are you?" I told him that I was 34. He said, "By the time you finish all the studies you have planned in his protocol, you will be sixty!"(I proved him wrong and finished it all in my three years' fellowship). He was a conscientious uspervisor, but gave me all possible freedom to pursue my research plans. This was a most exciting and challenging time in my life from the research point of view, but I wrestled with the loneliness and cultural shock that any immigrant goes through, especially an immigrant from a traditional Indian background. In Patiala, my younger brothers and sisters had all lived with me, studying at the University where I was a teacher, and I had many friends and acquaintances in the small community. In London it seemed I had nothing irl common with the people around me other than being a human being. To overcome my isolation I kept myself extremely busy so that I did not have the time to think about anything other than my research work. Sir Stewart was not only very charming, pleasant, and kind, but also extremely generous with his time and interest. He became my mentor and helped me in many ways.
I had and continue to have great problems with language, being not only a non-native English speaker, but also dyslexic, and Sir Stewart took the time and trouble to go over my early papers with me, correcting and explaining. He had a wonderful command of English himself, and his writings were always simple, lucid and elegent. I learned a great deal from him - how to write simply and clearly, at least, though I could never achieve his elegance. Sir Stewart also had a phenomenal memory and energy. His secretary, Miss Rosamund Soley, was even more helpful to me and greeted me always with a smile. She was particularly skilled at finding references (before computers!) and all the bibliographies in Duke-Elder's System of Ophthalmology were cmplied by her; I learned the tricks of that trade from her.
After a few month's English reserve, the other staff members of the Institute gradually started to become friendly and helpful. At that time the Institute housed a distinguished group, including Norman Ashton, Terry (E.S) Perkins, Barrie Jones, Keith Lyle, David Maurice, David Cole, John Gloster and Jeff Arden, to name only a few. One person who helped me tremendously with my experimental studies and became a close friend of mind was Mr.John Edwards, the chief technician in the department of experimental ophthalmology. Several young Americans spent their fellowships at the Institute at that time and became my friends. One particularly close friend from those days was Paul Henkind, who joined the Institute about- a year after I went there. I enjoyed his friendship until his death. Hisako Ikeda and Helga Kolb were new arrivals at the Institute about the time I went there, and we started a friendship which I still cherish.
At the very beginning of my studies, I had what seemed like insuperable problems with the experimental production of optic isc edema, because no reliable model was available. However, once I discovered the intracranial balloon method and got over the teething troubles, my studies started to give new information - for instance, that fenestration of the sheath of the optic nerve relieved optic dis edema in raised intracranial pressure. This observation formed the basis of the procedure now frequently used in. idiopathic intracranial hypertension. During that period I discovered that central retinal vein occulusion was of two types, ischemic and nonischemic - an idea that was scoffed at by the pundits at that time. A famous American Professor of Ophthalmology, while visiting the Moorfields Eye Hospital, told me that my paper in the British Journal of Ophthalmology describing that finding "has done more damage to the subject of central retinal vein occlusion than anything else and should not have been allowed to be published." Time has vindicated me; now it is well-established that clinically central retinal vein occulusion is of ischemic and non ischemic types, with totally different course, prognosis and management. My work on the pathogenesis of optic disc edema was accepted for my Ph.D thesis for the University of London [Figure - 4]
When my Beit Fellowship finished after three years, I had to make a tough choice - go back to India and say good-bye to any serious ophthalmic research for lack of facilities and funds, or stay and try to make a career in British ophthalmology. I decided for the latter in spite of the very heavy odds against me. To go up the academic ladder in British ophthalmology I would have to undertake a local Residency and pass the examinations for the Fellowship of the Royal College of Surgeons (equivalent to the American Board in Ophthalmology), and I knew that the pass rate was only about 25%. Otherwise I would have no real future in clinical ophthalmology, and I now knew I wanted a career in patient care, research, and teaching To fulfill the requirements for the Fellowship, I spent one year as a Senior House Officer at Birmingham & Midland Eye Hospital. In 1965 I came back to the Institute of Ophthalmology and Moorfields Eye Hospital, London, as Lecturer in Clinical Ophthalmology with Professor Barrie Jones. There I extensively used the newly discovered fluorescein fundus angiography for diagnostic purposes as well as in clinical and experimental research. My experimental studies dealt mostly with the in vivo blood supply of the optic nerve head and glaucoma. In London, in addition to working at the Institute on research projects, I had commitments at three widely separted clinical ophthalmic establishments to see patients, do surgery and cover for emergencies; this required many miles of driving through the back street of London practically daily. I sometimes thought that I would have made a good taxi-driver! In 1969 I passed the examinations for Fellowship of the Royal Colleges of Surgeons of Edinburgh as well as of England - the latter not because I had to, but simply to prove to myself that I could. Those were the hardest examinations I ever had to face.
In October 1969 I moved to the University of Edinburgh as Senior Lecturer (later Reader) in Ophthalmology and Consultant Ophthalmologist to the Edinburgh Royal Infirmary [Figure - 5]. It was a small Department of Ophthalmology, clinically oriented, and I had to build facilities for my clinical and experimental research from scratch by obtaining a research grant from the Medical Research Council. Most of my experimental research had been in primates, and the medical school at Edinburgh had no primate research facilities. However, a private drug testing company 25 miles south of Edinburgh allowed me to use their primate housing facilities, provided that I build and equip my own laboratory on their premises. I traveled there twice a week with my research, spending the other days at the Eye Pavilion of the Royal Infirmary doing my clinical, operative and teaching work.
I passed a very important milestone in my life at Edinburgh. I had been a confirmed bachelor all this time, giving all my attention to ophthalmology; but in Edinburgh I met a Scotswoman, a former Classic scholar who was now Administrator of the Eye Pavilion, and at the age of 44, I married (perhaps by delaying until the age when many men are having "second thoughts," I made the right choice the first time around; I certainly have had no cause to regret it yet!) I acquired not only a wife but also a literary editor who has helped me tremendously with my publications ever since.
In 1972, because of a number of professional factors, I very reluctantly decide to leave Britain and move to the United States. To learn more about the structure of U.S. ophthalmology, in order to make a logical and correct decision, I wrote to Dr.Fredrick Blodi, whom I had met at many European and British meetings over the years and grown to like and respect. As an immigrant to the U.S.A himself, I thought, Dr.Blodi would be more aware of what is involved in such a move. so I wrote to him for advice. To my surprise, within a week I got a letter from him asking me to join the university of Iowa's Department of Ophthalmology. I accepted his offer gladly, because my wife and I had visited Iowa city a year earlier; I had liked the department and my wife liked the small, friendly city.
The immigration bureaucracy of the United States took its own time, but my wife and I, along with our six-week-old son, finally arrived in Iowa city in deep snow in January 1973. We have now spent 18 years in Iowa city and consider it home. In keeping with the departmental philosophy, instead of covering all of ophthalmology in my clinical practice as I had always done in Britian, I gradually concentrated on ocular vascular disorders and optic nerve disorders (including glaucoma) both for clinical practice and for clinical and experimental research. At the same time, I maintained my interest in other fields, particularly medical ophthalmology, scleritis, episcleritis. uveitis and cataract. In 1987, the University of London, after a critical evaluation of my published research work in the field of ocular circulation in health and disease and optic nerve disorders, awarded me its highest and most prestigious degree: Doctor of Science.
Having lived for the first 34 years of my life in India, for more than 11 years in Britian, and now for over 18 years in Iowa city, I have had a varied experience of very different cultures and working conditions. This has given me a deep sympathy with "outsiders" of all kinds. The immigrant or member of a minority group is never wholly accepted and never entirely comfortable. As Samuel Johnson said, "No man willingly leaves his own country", the emigrant pays a very heavy price, particularly emotionally and psychologically, however, great the benefits of life in the new country. The motive for emigrating varies from person to person; for me it was the pursuit of a productive research career. No one who has not experienced it can conceive of the cultural shcock that every immigrant goes through. It is an emotionally draining experience. A person going through cultural shcok, as well as coping with a foreign language and probably new technologies, can work at only a fraction of his normal capabilities and needs the understanding, kindness and help of his collegues. The immigrant of many years' standing, like me, funds that he no longer belongs in the country that he left and yet will never entirely belong to the country where he now lives; he never experiences the pleasure and comfort of being "one of the boys",of having a place in the establishment, and understanding effortlessly all those signs and references that link people to each other. On the credit side, however,he had become a "world citizen" with an understnding of human nature and society that is never available to those who have lived in only one culture.
Having had first-hand experience with three different health-care delivery systems (India, Britian and the U.S.A.), I have come to some conclusions about their relative advantages and disadvantages. I have also found that most U.S. Physicians have mistaken ideas about the nature of medical practice in the other two countries. I think that these stem partly from the fact that they judge American medical care by what they are practcing, which is no doubt the most technically advanced in the world. Most of them, however, do not see the poor Americans who have no insurance, the mentally ill, the old, the homeless and their children, who are certainly not getting the best health care in the world.
Given that no society can ever meet 100% of the possible health care needs of its population, health care has to be rationed in some way[ India is a poor country, and its health care is rationed partly by geography and partly by availability of equipment. Hosptials are essentially run by the government, and there is very little private medicine. Patients get free medical care in the governemt hospitals; they may have to pay for drugs, but not for consulations or routine tests. The hosptials are not well equipped with the least technology, are over crowded, and the quality of service is not excellent, but it is much better than none at all. In Britian the National Health system provides medical care to all all. In Britian the National Health system provides medical care to all but a welathy few who want to have special ammenities. In Britian, care is rationed mostly by time; one can get good quality emergency care prompty, but must wait for elective surgery and other non-urgent situations. Hospitals look rather Spartan and the latest high-tech equipment is not available everywhere. Still, mental health services, maternal and chi: care, geriatrics, and public health are excellent.
Different patterns of care produce very different expectations and attitudes toward physicians and the health care system. British patients trust and respect their physicians enormously because they know the physician has no financial interest in the medical care being prescribed. In India, similarly, patients feel highly obliged to the physican. In the U.S. the patient-physician relationship is considered much more a matter of business; patients fell (justly, to some extent) that the doctor is there to make money from them. However, attitudes do very in different parts of the country; I have found Iowa patients, on the whole admirably straightforward and trusting people. The "business" attitude of American medicine is one of the factors which unfortunately make U.S. medicine the most expensive in the world; many investigations and tests are done in the U.S., not for clinical reasons, but simply to safeguard against medicolegal problems. Also in the U.S., medical training places far more reliance on tests that in India and Britain, where there is great stress during training on developing good clinical acumen and not relying on tests (which may not be available in India). A U.S.trained physican would feel totally inadequate in an Indian setting. Each system has its advantages and disadvantages and none is perfect. I, personally, feel the British system is the best of the three from the point of view of combinning the greatest good for the greatest number with economy.
Finally, an autobiographic sketch inevitably leds one to consideration of one's basic attitudes and philosophy, which greatly influence one's ahcievements and attitudes and perception by others. The attitudes and philosophy are shaped first by one's orginal culture and upbringing and then by one's professional and personal experiences. In Indian society, humility and deference to elders and superiors ' is considered basic good manners; however, when I moved to the West I soon discovered that my shyness and humility were misinterpreted as weakness and ignorance. Persons with very average capability and intellegence completely trampled over me. To survive, I had to completely change my public manner. I hated it, but it was a necessary cultural adaptation. Among my deepest beliefs is the statement, "Magna est Veritas et Praevalebit" ("great truth and it shall prevail"). I cannot countenance dishonest or shoddy research, prevarication or hypocrisy. I avoid politics of any nature at all costs. I am an iconoclast. Having been compelled from the beginning to be my own director of research, investigator and, quite often, technician, I have kept myself informed about all aspects of my research from the most elementary to the most complex. I have learned how easy it is for research to be completely vitiated by low-level carlessness or ignorance. I know exactly what has gone on at each setp of each project from inception of publication. I differ seriously with research directors, who do not think it necessary actually to do the research work themselves, and delegate it to resarch assistants or students, with only cursory "supervision". Not uncommonly the final paper is written by research assistants, and the director finally becomes the spokeman of the research No wonder mistaken and even suspect results are produced!.
Similarly, I disapprove of retrospective studies. Information recorded on a routine visit to a busy clinic (even in the best of institutions) can be veyr inadequate, and extracting information from such old records is extremely conducive to wishful thinking. Often the patients whose records are used were never seen by the investigators, nor followed systematically, and the information is derived from dubious sources, with some guessowrk thrown in. Their results are extremely hard to disprove, however, which makes them on balance a disservice to science. It is very easy to introduce misinformation into the literature, especially if it is attractive and fits well into armchair theories, but it takes years of time and •effort to root it out. Prospective studies take a lot of time and effort to do, but the results they produce in the end are far more reliable and scientifically useful.
I consider the whole enterprise of scientific research as being a little like running a restaurant. The manager of a restaurant may take no interest in the cooking and what ingredients go into it, but may assure the customers that everything is of the best, and claim all the credit. In the vry best resturants, however, the manager takes an interest in the whole process from planning through buying, cooking 'and serving; in such esatblishments the results are much more likely to be excellent and the customers will not be disappointed.
Thus my mother's long-ago notion and the study of medicine have transformed me from a simple country boy in a remote village in India to whatever I am now; it has been a hard struggle but it was adventurous, challenging, exciting and, above all productive and rewarding.
I am grateful to my wife Shelagh for her help in the preparation of this manuscript.
| References|| |
Francois J Neetens A: Vascularization of the optic pathway. I Lamina cribrosa and optic nerve. Br.J Ophthalmol 38:472-488. 1954.
Francois J Neeteens A, Collette JM: Vascularization of the optic pathway. II. Further studies by microarteriography of the optic nerve Br J Ophthalmol 39:220-232, 1955
Percival S: A History of India Vol 2. New York, Viking Press, P 238
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]