Going by his words, understanding the human brain is far more complex than comprehending the entire solar system. Veteran neurologist and celebrated author Dr K Rajasekharan Nair, son of the late scholar Sooranad Kunjan Pillai, is someone who has carved out a place for himself in Malayalam literature as well as Kerala’s medical field.
Former director, professor and HoD of neurology at the Thiruvananthapuram medical college, he shares his thoughts with TNIE on the medical scene’s inclination towards super-specialities, rise in autism cases, scope of AI in medicine, how gut feelings work, and of course tips to identify a ‘good’ doctor. Excerpts
You are a rare combination of a neurologist and an author. How did you get into writing?
When young, I wanted to do my master’s in literature and become a writer. There were poets and philosophers in my father’s family. Mother’s family had mostly technocrats. She insisted that I opt for MBBS. At the time, only 11 candidates from Thiruvananthapuram would be given admission to the Trivandrum Medical College. There were only 58 to 60 merit seats in total. My father had suggested that I join the Sanskrit course. But I wanted to do MBBS. The only advice he gave me was, “Don’t ever be a beta man.’’
Have heard that becoming a doctor wasn’t your original aim, and that an astrologer, who visited your house along with poet Vallathol, predicted that you would become a doctor...
(Smiles) Yes. Many editors and writers visited our house to meet my father (Sooranad Kunjan Pillai). Vallathol, P Kunhiraman Nair and G Sankara Kurup were among them. An astrologer once accompanied Vallathol. I was a child then. He held my hand and asked me what I wanted to become, to which I replied, “An engineer.”
He looked at me for some time and said: “No, not an engineer, but a doctor.”
Do you believe in astrology?
I neither believe nor disbelieve. What has to happen will happen. Why know about it in advance?
You believe in fate?
I prefer to call it genetics and epigenetics. My father died at the age of 85 and mother at 87. I’m 85 now and have passed the expiry date. It is genetics. Epigenetics is the change that happens to us because of our behaviour and surroundings. It has the capability to change genetics as well.
Nature versus nurture... are you saying our genes will change with our nature and situation?
Genes won’t change. Life is unpredictable. Nothing in medical science is predictable. There are instances where people survive despite a 100 % mortality chance. Medical field is highly unpredictable; its result depends on the practitioner’s sincerity. I believe in William Osler’s words that a practitioner should be like a sea promontory. The waves will dash against you and try to pummel you down. Stay calm, the waves will recede sooner or later. It requires a lot of training. One has to spend 13-14 years for medical education. A good medical practitioner is a student till death.
What’s the secret of longevity?
Do not yearn intensely for anything. It isn’t worth it. Everyone has to die. Lead a decent life. Ayurveda has a good answer for this. ‘Ati Sarvatra Varjayet’, meaning excess of anything is bad, be it food, sleep, or any such thing.
What’s the role of medicine if everything is genetically predetermined?
Genetic anomalies can be corrected to some extent. I’m not referring to stem cell therapy here, rather to the fact that many diseases we acquire can be prevented.
What changes have you noticed between the time you started and now?
When I began my career in General Medicine, our outpatient department would admit two to three patients with amoebic hepatitis every day. Today cases of amoebic hepatitis are referred to gastroenterology surgeons. Back then, we had no choice but to treat amoebic hepatic abscesses ourselves. Now diagnostic machines have taken over much of the process.
As someone who introduced super-speciality courses in neurology, what’s your view on the current medical scenario that is skewed towards super-specialties?
There are both positives and negatives. Earlier, when patients visited doctors, the doctor would talk to them, reassure them, and send them home if nothing serious was found. Today, patients often think of consulting a neurologist even for a simple headache, while the reality is that 90% of headaches are just tension headaches. Only rarely do symptoms point to something serious.
How important is intuition or gut feeling in diagnosis, as a neurologist?
There are two ways of knowing. One is called bottom-up knowing. The other is top-down. A knowledgeable person has top-down knowledge. He’d have lakhs and lakhs of bits of information stored. Intuition means recollecting previous knowledge. Past experiences guide you. Your gut feeling may be right most of the time. From embryology to clinical medicine, all of that percolates at the same time. I haven’t seen new students for 30 years, so I don’t understand their mentality. They can diagnose only if they have CT, MRI, and all such paraphernalia.
In the medical world, how much cure can AI give a patient?
It isn’t much now. That doesn’t mean that it cannot happen tomorrow. Today, we use whatever tools we have. But compassion is not found in machines. I had a teacher named K N Pai. He did not have a sharp intellect, but if he placed his hand over someone and said ‘You’ll be fine’, even a person on deathbed would get a glimmer of hope. We call it haptics, and it is indeed a skill. Touch involves empathy, the ability to transform into a different person altogether.
You once said that despite great progress in science, human beings still don’t understand their own brain. Does that mean we haven’t fully understood our closest companion, the brain?
Compared to understanding a solar system or even a galaxy, understanding our brain—which weighs only around 1,380 g—is far more difficult. The calculations involved are extremely complex. There are around 100 billion cells inside the brain. Each neuron has predetermined destinations it can connect to. Each neuron has synaptic connections. There are around 500 trillion synapses. All these synapses do not work simultaneously. The brain is actually the best disintegrator of senses. When we look at a human, we don’t see the computer-like system working inside. Right now, while you are sitting here listening to me, you are not consciously noticing the sound of the air conditioner. This is because the brain is tuned to select what is required.
Does that mean we only see and hear what we want to?
Not what we want, but what the brain feels necessary. There’s a book named ‘A Vision of the Brain’, written by Semir Zeki. He studied vision alone for 50 years. After all that research, at the end of the book, he honestly says, “I don’t know why I see what I see.” Your brain makes you see what you want to see. Nothing more. When you are reading a book, you don’t notice the ant or things passing by on the side. Does the brain deceive us? Yes, it does. If we talk about brain disorders, it becomes very interesting. There’s a brain disease called simultanagnosia. If a patient with this condition is shown a picture of Krishna alongside gopis and a cow, a normal person would see Krishna, the gopis, and the cow... all together. But a patient with this disorder, if asked to look at Krishna, will see only Krishna. If asked to look at the cow, I will see only the cow. Nothing else. The totality of vision is completely lost.
This isn’t something extraordinary. Lewis Carroll wrote ‘Alice in Wonderland’. The strange visual experiences described in the book were based on abnormalities he experienced during migraines—falling sensations, shrinking, and enlarging. These are called micropsia and macropsia. Macropsia is a visual distortion where objects appear larger than they actually are and micropsia is a disorder where objects appear smaller.
Is this why we say that most artists are slightly neurotic?
Everyone can have something or the other. Only one person openly said, “I am mad,” and painted accordingly -- Salvador Dalí. There are artists without such problems, too -- Picasso, for instance.
Can being neurotic trigger creativity?
There’s a difference. We take pride in believing we are all ‘normal’. But what does normal mean? Often, normal comes with the assumption that one isn’t creative. But everyone has inherent creativity. For example, if there are no vegetables to cook, you go into the yard, pluck some drumstick leaves, and make a dish. That is a creative act. Creativity is finding something useful.
How do you view creativity?
In an article I wrote at the age of 28-29, I described Ramakrishna Paramahamsa as ‘abnormal’. My friend Bhaskaran Nair, a fine science writer, questioned this from a medical and philosophical standpoint. He said in medicine, people are trained to focus on hyponormal — conditions below what are defined as normal. We rarely examine the hyper-normal. He posed a simple question: “What if Ramakrishna Paramahamsa wasn’t abnormal, but hyper-normal? Would you reject the idea outright?” Over the years, the more I reflected, the more I felt Bhaskaran Nair was right. Hyper-normality does exist. Why should we deny it?
Statistics show a rise in autism cases. How will you explain that?
One of the reasons is better awareness and diagnosis. Autism is not a disease, but a spectrum. People with Asperger’s syndrome are very common. We encounter them every day; someone who follows rigid routines and gets work done. Many of them possess remarkable abilities. While they may struggle socially, many are savants... their capacities are narrow but profound. Oliver Sacks’ work shows that what we call ‘deficits’ are often compensations -- alternative neurological arrangements that give rise to extraordinary perception. They aren’t abnormal but have minds that function beyond familiar limits.
Some even say there’s a link between parents’ lifestyle and rising incidence of autism. Any truth in that?
Many studies attempt to link autism to parental lifestyle, food habits, or patterns of living. A statistical correlation does not automatically mean that’s true.
Studies show that genetic disorders among newborns are on the rise...
This is not something we can dismiss outright. What we often underestimate is how drastically our environment has changed, largely without our conscious awareness. Background radiation levels, the nature of the food we consume... we are exposed to substances every day, the long-term effects of which we barely understand.
Is deviant behaviour a neurological problem?
According to studies, the brain has two types of chemicals: Angel’s Cocktail and Devil’s Cocktail. In Angel’s Cocktail, the important one is dopamine which makes one happy, content, and satisfied. The second is serotonin by which you are forced to become happy. The third is oxytocin which makes you love others. In contrast, the Devil’s Cocktail makes one angry, sort of devil-like, such as adrenaline. If serotonin is manipulated, depression will go away. Serotonin is destroyed by an enzyme, which can be blocked using Specific Serotonin Receptor Inhibitor (SSRI). That raises serotonin levels and you are relieved of depression. The problem is that psychiatry has not reached mainstream medicine. It will one day be part of a large spectrum of science called neuropsychiatry. We’ll then get to know about the biological background of schizophrenia, depression, etc.
Does deviant behaviour have a genetic basis?
Yes. Sometimes, it can be extremely severe. For example, if there’s some problem with the ‘Y’ chromosome, you become a very violent and diabolic person.
So, a person can’t be blamed for deviant behaviour?
To be frank, if you think deeply, no, to an extent. In our time, there were no genome studies. So, we didn’t go that deep.
Can increased dopamine levels become a problem?
Yes, very much so. It can drive a person completely crazy. Dopamine was the world’s first designer drug... specifically created to treat a condition. Patients who are bedridden and near death would suddenly sit up when given dopamine. At a certain stage, they would even dance. But once the dose crosses 2 to 3 g, they would plead to stop because they experience severe vomiting and distress. If its dosage increases, they would go crazy. If dopamine levels exceed a certain threshold in one pathway, the person becomes utterly psychotic. There is a term in the Upanishads -- asidhara, meaning the edge of a sword. Walking this path is like balancing on that edge.
Is there really something called the ‘mind’? Where is it located?
The surgeon who did nearly a thousand brain surgeries in one of the greatest hospitals in the world was an American. He has done everything—stimulating, erasing, and manipulating every known part of the brain. After having done all that, he said, “I don’t know where the heck something called mind is situated.” There’s a book of his, ‘No Man Alone’ – worth reading.
Does the brain have a gender?
Yes.
You mentioned the brain making decisions. Does the brain have a mind independent of conscious awareness?
I don’t know the real answer, but I can detail it. The mind is essentially a compilation of consciousness, awareness, and decision-making capacity. Several studies at Yale University explored this, particularly those by Patricia Goldman-Rakic. She proposed that what we experience as the present is actually the past. According to her, the frontal lobe predicts the next word another person is likely to say. This predictive capacity forms the basis of what we call the theory of mind.
Is there something called soul?
I wish I knew the answer. If you are willing to take the effort and time, read my book ‘Njan Enna Bhavam’. It is not a silly book; I prepared it with a lot of effort and energy. The book begins with the feeling of sense and selfhood, which dates back over 3,500 years.
Are patients in coma internally conscious of their surroundings?
There are two scenarios: the first is when you are unconscious, but still remain minimally conscious. The worst is when you cannot move even a single muscle in the body except those in the eyes, but you are aware of what happens around you. This is called locked-in syndrome, where the damage happens in the upper part of the brain stem.
You have said that all children are geniuses till the age of seven. By this, do you mean that we should give them more input until then?
I would suggest so. It is irrelevant what you teach your children. My father had a photographic memory. He would teach me poems, explain their interpretations, recite them again, and then I had to recite them. All this would happen, walking along the edges of fields. When it came to my daughter, I would use the same technique. I would teach her a poem on the way, and she too would learn it. It is possible--because each neuron in a newborn’s body will have only 2,500 synapses. This increases up to 15,000 synapses as they grow up to the age of seven. Later, this would gradually drop to 7,000. Even in the womb, the child can hear from the 24th week. But I don’t know what they hear.
Does this mean that a child can hear external sounds, like music?
To an extent, yes. This doesn’t mean that they’ll be able to understand it. The brain needs to develop a lot, till the age of three-and-a-half to four years, to become aware. But they will certainly be able to hear.
Should we burden their childhood because of this?
I started learning Sanskrit at the age of three-and-a-half. And I haven’t regretted it. I have only benefited from it.
It’s said that some communities, like the Jews, are more intelligent than others...
I don’t think so. It is all about the circumstances they grow up in – Sigmund Freud, for instance. His mother used to call him ‘Golden Siggie’ or so. A child growing up in that kind of a background has no other way but to end up like him. He became one of the most successful and popular people the world has ever seen, though I disagree with him on several aspects.
But shouldn’t children also have talent in them?
God gives us children with all talents. It is about how you use those talents. Teach them not to hurt others and always have a smile, which never costs anything.
TNIE team: Cithara Paul, Anil S, Unnikrishnan S, Aswin Asok Kumar, B P Deepu (photos) Pranav V P (video)