One Victory-Many Ahead

It is a matter of great pride and joy that the Supreme Court of India has decided today that the proposed 27% quota hike by the union government favoring OBC's in higher educational institutions is based on a fallacious premise.
Its satisfying to note that all we did last year has at last borne fruit in some significant manner. Many battles lay ahead but I am sure that victory will eventually be ours.

Journey

I was sitting in the OPD today seeing my patients when it occured to me more forcefully than it has in a long time that most of the patients I see are brought by old, infirm parents. Their wards (patients) do nothing productive that i know of, live in a state of perpetual drug-induced bliss/obtundation, and quite frankly I sometimes wonder how they make their ends meet. I mean, spending something like Rs500 (something that even i cant dream of doing on a consistent basis) takes some doing espescially when it is done for years and months together. And what is espescially striking is the fact that they keep coming back, keep hoping and most of the times they end taking the drugs, but the only thing that seems to work is age. Most people quit only when they simply cant keep up with it longer.
Life for these people is truly a harsh journey with no respite. But they keep going on, until the next fix, until the next few hundred rupees, begged, borrowed or stolen. And until the next time they are brought, willingly or otherwise to the drug deaddiction centre for another round of admissions, invstigations, treatments and relapse.

Original Thought

Its humbling to realize that there is probably no such thing as an original thought. Now "that" is an original thought!!!

Freaky weather

Weather in chandigarh and surrounding areas is increasingly becoming awry and unpredicatable. There was heavy rain somedays back, when I took this picture. Damaged crops, and screwed up schedules and timetables. As if that was not enough, there started hailstorms. Huge big blocks of ice falling out of the sky and made an awesome racket as it did so. Woke up due to that racket and took this pictures from my hostel room balcony. Worried about the car getting dented but luckily no pproblems there.

Couple of days ago, an intense squall. Rain and wind, snapped power cables, leaves and flowers everywhere. Great day for photography.
And finally now, summer is advancing everyday. Its getting warmer and more uncomfortable, the fan is a welcome relief sometimes. Power cuts and sweaty nights will soon be upon us. And then there is this small matter of the world cup and the miserable Indian team.
I wonderi f I should now write exclusively on psychiatry and let this blog be known as a thinking mans blog!!!!

A Rant

How does it feel, to stay awake until 3am only to see your national cricket team make utter and complete fools of themselves and 1 billion (plus a few million) other people who follow this game in the country???
Well, I am sure many would have wanted many members of the team to be flogged publicly and quite frankly, I think its too good for them.
After having lost to Bangladesh (still cant believe it, Bangladesh), they beat Bermuda (fat policeman et al.) only to lose most humiliatingly to Sri Lanka and now we are collectively out on our collective butts of the super 8's of the 2007 world cup.
Everyone has an opinion, And here is mine. Sachin tendulkar needs to concentrate on his restaurant and his sunfeast biscuit ads, Harbhajan Singh already has a 4 kanal house in sector 9 Chandigarh, he has arrived. Ajit Agarkar should probably be given a benzodiazepine or better still a typical antipsychotic like haloperidol, maybe that will cure his grandiose delusion. The others, well....I dont know, I just hope they develop incurable motion sickness and aircraft phobia. That will probably get some new faces into the Indian cricket team.
And as for me, I woke up at 7am, got ready, saw some 10 patients suffering from various hues of drug addiction, abused the cricket team some more and am now ready to get some sleep and make up the shortfall.
BTW, Bermuda might still defeat the Bngladeshis and let India sneak in through the back door, but actually I hope they lose. Cant bear to see them lose and lose sleep over that in the near future.
On a serious note, those buggers owe it to the Inidan public to make some heads roll now, we cant work indefinitely on reputations alone.

Empowering Psychiatry

This and the previous article were written for publication, could not resist posting them here. This about as much serious writing that I can do....

The practice of medicine has a history as old as that of mankind. The first healers were probably fellow hunters and gatherers or members of the community. Gradually this role became more specialized and was taken over by priests and witch doctors. However, the one fact that remained inviolate was that the healers and the patients that they treated were from the same social and cultural milieu, and therefore the problems that they presented with were healed using the resources and keeping in mind the sensibilities of that culture. This form of healing is still prevalent in primitive societies that are yet untouched by our progress. This form of medicine is characterized by a practice that is more an art than a science in that it is dependent on a patient-healer relationship and less on an understanding about what actually works in the therapeutic process.

With the growth of civilizations, each civilization derived a system of medicine that was in tune with its own sensibilities and philosophies. Keeping aside the merits and demerits of the various systems of medicines, the form of medicine that we practice today is a product of the European post-renaissance mind. This period of European history is probably the single most defining feature that shapes our world as we know it. As a result of the extraordinary freedom and ambition that this thought fostered, Europeans were able to rule over the entire world and were also able to disseminate their own philosophy and scientific temper wherever they ruled.

This growth of scientific thought though marked by various upheavals eventually crystallized itself in the principles that dominate much of modern medicine that is now called biomedicine. These principles are also called those of objectivism. These are as follows:

1. There is only one reality. By carefully dividing and studying its parts, the whole can be understood. (Realism)

2. The knower can stand outside of what is to be known. True objectivity is possible. (Positivism)

3. One event comes before another and can be said to cause that event.

4. Explanations from one time and place can be generalized to other times and places.

5. Determinism.

6. Nomothetic (search for universal laws). (Maykut and Moorehouse, 1984)

These principles imply that the truth is absolute and generalizable, is independent of the observer and the observed, and that the observer needs to be an objective dispassionate observer to get to the truth. These principles have enabled modern medicine to scale the heights it has, today we face new challenges with hope and confidence in the background of past victories and lives of millions have been saved and become better in many ways. On the other hand however, these are admirable qualities for a scientist, but when these principles are seen through the prism of medical practice, the results are quiet different. As McWhiney (1988) has put it, “Patients suffer from diseases which can be categorized in the same way as other natural phenomena. A disease can be viewed independently from the person who is suffering from it and from his or her social context. Mental and physical diseases can be considered separately. Each disease has a specific causal agent, and it is a major objective of research to discover them. Given a certain level of host resistance, the occurrence of disease can be explained as a result of exposure to a pathogenic agent. The physician’s main task is to diagnose the patient’s disease and to describe a specific remedy aimed at removing the cause or relieving the symptoms. He or she uses the clinical method known as differential diagnosis. Diseases follow a defined clinical course, subject to medical interventions. The physician is usually a detached neutral observer, whose effectiveness is independent of gender or beliefs. The patient is a passive and grateful recipient of care”. Quite obviously, a physician who follows the principles of objectivism may lose the art of healing at expense of the science of biomedicine.

In psychiatry, a major philosophical underpinning has been that of the Descartian mind-body dualism. This implies that mental processes are separate and distinct from physical or somatic processes. This seemingly innocuous statement has held sway and guided thought for over three centuries and has given rise to the notion that mental processes and more specifically mental illnesses have no physical or neural basis and it’s all, quite literally “in your mind” (Hyman, 2000). The initial school of empiricism and deep involvement as exemplified by the rich descriptions of psychopathology and nosological attempts by Jaspers, Bleuler and Kraeplin but to name a few gave way to the massive avalanche that was the Freudian thought. This gave for the first time a framework for understanding what could be observed, gave respect to personal integrity, and a less stigmatized perspective on mental illness. This understanding had no need and no place for biological systems and hence the study of the above was either neglected or even discouraged (Kandel, 1998). This model of psychiatry that held sway until recently was almost all art and little science. The model of practice and research was subjective. The therapeutic process one of cooperation and sometimes equality. Most of all, human behavior was seen as voluntary rather than deterministic.

In recent years however, there has been an apparent convergence in the philosophies of biomedicine and psychiatry. Psychiatric disorders are now viewed as requiring explanation or etiologies, diagnoses made on universal truths, and all based on the principles of objectivism. Certain robust assumptions can still be made; these being those that most of psychiatric thought today rest on:

1. All mental processes are operations of the brain.
2. Genes and their products are important determinants of brain function.
3. Social or developmental factors influence the expression of altered genes that lead to mental illness.
4. Learning can influence gene expression.

(Kandel, 1998)

If examined carefully, these statements have layers of meanings. At the very basic level is the assumption of a single universal truth regarding the universality of brain function and its psychological correlates, and the influence of genes. It also importantly, makes enough provision for the possibility of the uniqueness of human experience and learning in the etiology and progress of mental illness.

The practice of biomedicine has increasingly been subject to voices of dissatisfaction from the clinicians. This has gained momentum in the recent years with the decline of the family physician and the rise of managed care with treatment algorithms, the demise of the patient and the arrival of the case has been lamented. Response to these challenges have come about with the advent of models such as the biopsychosocial model (Engel, 1977), and the social constructivist model of medicine (Wilson, 2000) amongst others. But it is to be noted that these models have remained on the fringes of biomedical practice.

This essay aims to make a case for a return to a healthier sensitivity in the practice of biomedicine using the practice of psychiatry as a template for the same.

The following are the paradigms that are followed in psychiatric practice that have a relevance to the practice of biomedicine:

1. A social and cultural context: In the search for the universal truth and in particular the truth about the nature of the disease-patients would be expected to have diseases that follow defined clinical paths. It is also worth asking whether by that standard, can an illness be considered separate from the individual who is suffering from it? Can the behavior of a disease in one patient predict how it will appear in another? Is the same disease consistent in presentation across different cultures? Or do social, cultural factors, stress, migration, affluence have a role in the causation, presentation, course and outcome of an illness. Doctors while being trained become enculturated into a particular stance of objectivism. While this may be useful for analyzing data or deductive reasoning, it may not hold true in clinical situations. Psychiatric research and practice on the other hand has had to contend with these questions as a matter of survival rather than as a matter of curiosity. This is simply because mental illness by its very nature was supposed to be an affliction of a particular class or race and hence not capable of being a universal truth. Though the matter of the existence of mental illness has been settled, this has inculcated a healthy respect for cultural and social mediators of all aspects of mental illness. Going back to Kandel’s framework, a universal truth is acted upon by many other realities that are unique to the individual and these are the prism through which the patient presents. Thus, an illness should be seen as arising from a matrix of cultural beliefs and biological systems and this interaction should be taken into account in any formulation. The doctor would also do well to be aware of personal prejudices that may be socially and culturally determined. These prejudices may influence decisions with regard to diagnosis, treatment and general demeanor.
2. The primacy of the doctor-patient relationship: Day and Semrad (1978) said: “The essence of therapy with a schizophrenic patient is the interaction between the creative resources of both the therapist and the patient”. While this may not be apt in all cases of biomedicine, however it does affirm the primacy given to the relationship between the patient and the doctor. Doctors may have understandably little time or energy to spend in an effort to move away from the paternalistic mode of treatment that we follow. However it must be affirmed that doctor-patient relationship do influence outcomes, and the doctor cannot afford to remain a neutral observer of natural phenomena. Medicine has rightly prided itself on the sanctity of this relationship, but as is evident in the media and in our experience, this central fulcrum is being eroded gradually. A part of the blame must attach itself on the physician for his inability to see the patient instead of the case. As Toulmin (1993) has pointed out, “The misplaced emulation by physicians of ‘science’ is . . . the real reason why the general public is alienated from professional medicine. Inevitably and properly, the focus of the natural sciences is on the general rather than the particular, the universal rather than the existential . . ..….so instead of seeing individual subjects as ‘patients’ afflicted with various ills, biomedical scientists legitimately regard them as ‘cases’ of general syndromes or conditions; their subjects are therefore interesting only incidentally, to the extent that they exemplify some pathological entity that is interesting in itself”. His resolution is to refocus back to the original goal of medicine; to relieve suffering in the individual patient. The doctor-patient relationship is a moral exercise that guides a patient through the most significant aspects of life like birth, death, illness and healing. A way to make this change come about is ascribing to the patient the principle of voluntarism rather than following a deterministic model that reduces a patient to a physiological process. Coming back to Kandel’s framework, as has been pointed about; learning can influence protein synthesis and the doctor is at a unique position to teach or advise the patient regarding change to healthier ways of living and the importance of social support in better outcomes.

The art and science of medicine follow radically different philosophies but their eventual goals are the same. Psychiatry is a unique branch of medicine where the two have learnt to coexist most fruitfully. With a little more involvement and attention to details, physicians can expect better outcomes and if not that more satisfied patients at the very least.

References:

Day M, Semrad EV. Schizophrenic reactions. In: Nicholi AM Jr., editor. The Harvard Guide to Modern Psychiatry. Cambridge, Mass: Harvard University Press, 1978, pp 199–241.

Engel GL. The need for a new medical model: A challenge for biomedicine. Science 1977; 196(4286): 129–36.

Hyman SE. the millennium of mind, brain and behavior. Arch Gen Psy 2000; 57:88-89.

Kandel ER. A new intellectual framework for psychiatry. Am J Psy 1998; 155: 457-469.

Maykut P, Moorehouse R. Beginning Qualitative Research: A Philosophic and Practical Guide. London: Filmer Press, 1984.

McWhinney IR. A Textbook of Family Medicine. London: Oxford University Press, 1988: 46.

Toulmin S. Knowledge and art in the practice of medicine. In: Delkeskamp-Hayes C, Cutler M, editors. Science, Technology and the Art of Medicine. New York: Kluwer Academic, 1993: 234.

Wilson HJ. The myth of objectivity: is medicine moving towards a social constructivist paradigm? Family practice 2000; 17:203-209.

Filler-An article

What is Psychiatry?

Thoughts, emotions, cognitions and perceptions are the basic substrate of the experience of being ‘human’ as we know it. These enable us to interact with others and live our lives in rich and rewarding ways. These also mould our behavior which is a reflection of the above. However, the demands of being a member of society invariably impress upon an individual to conform to certain limits on behavior. This is essential because deviance beyond certain limits carries in it seeds of decay and downfall of that society. Therefore, individuals who have deviated in behavioral terms from the norm of a particular society have always attracted attention and in the absence of knowledge, alarm and indignation as well.

Until a few centuries ago, all such deviance was explained as a result of forces such as demonic possession. This was because unlike most other illnesses, mental illness did not manifest in any physical handicap and observers were not able to understand why a person behaved the way he or she did. As a result, depending upon the thought prevailing at that time such people were either eliminated as being evil or later on segregated for life from the society. Except for a few exceptions, such was the case in most parts of the world. It took courage from a few enlightened people like Pinel who advocated a moral and humane treatment for such people, the reason being mainly an aversion to the horrible conditions that existed in the asylums of the 18^th century Europe.

However, as other branches of medicine such as neurology became established, similar concepts were extended to the study of those individuals who presented with nothing more than deviant behavior and abnormalities in thought, perception, emotion and cognition. It started to be recognized that mental illness existed and the study of such conditions was a part of medicine and not all in the ‘mind’ as Descartian dichotomy implied. It was only in Germany in the 19^th century, that such study became a clinical discipline. The term “Psychiatry” was termed by Johann Christian Reil in 1808 and was derived from the Greek “psyche” (soul) and “iatros” (doctor). The clinicians started to be called “psychiatrists”. Similar movements also started in other parts of the world. It is important to realize the paradigm shift that occurred at this time. Psychiatry as a clinical discipline exists only on the premise that mental illness ‘exists’, and it took close to 2000 years of recorded human history for that realization to come about. This truly was a momentous step.

However, efforts at finding out the physical basis of the symptoms of mental illness continued to be futile and in such a scenario, clinicians such as Freud and Jung are credited with giving a theoretical basis of understanding into the causes of mental illnesses. Such a step was extremely significant as science works on observation but cannot hope to progress without a hypothesis into its reasons. These theories held sway for most part of the last century until increasing dissatisfaction with these and increasing knowledge into the biological basis of behavior gave a new impetus and direction to psychiatric research and this phase continues until the present time.

Even in the present day, even though it is evident from various lines of research that mental illnesses have a basis in the dysregulation in the functions of the brain, a direct one-to-one relationship between specific abnormalities and specific mental illnesses has not been found. As a result and to avoid confusion, psychiatric diagnoses are made on the basis of agreed upon combinations of symptoms that are considered to be syndromes because of factors such as natural history, treatment response etc. this system driven by nosology has so far stood psychiatry in good stead and has given impetus to research and given psychiatry a scientific temper. It is regularly updated and takes into account cultural variations as well. It also acknowledges that much remains to be found out, and that the final word about mental illnesses has not yet been said.

As is evident, like all branches of medicine, psychiatry too is a science and an art. It is constantly shaped by new knowledge and new discoveries. But at the very basic level, it deals with prevention, assessment, diagnosis, treatment, and rehabilitation of the mind and mental illness. Its primary goal is the relief of mental suffering associated with symptoms of disorder and improvement of mental well-being.

Because psychiatry deals with problems in behavior and with people who cannot often make proper choices, a robust series of checks and ethical practices have been devised so that human rights are not infringed upon and the psychiatrist does not take undue advantage of the privileges that are bestowed upon him or her. As psychiatry is intimately related to the individual who as an organism is a member of the bigger system of society, the study of psychiatry has also fostered a close relationship with other disciplines such as sociology and psychology.

Psychiatry has flourished as a discipline and a profession because it has been able to fulfill a felt need of society. With growing demands from various quarters, psychiatry has split up into many subspecialties and many psychiatrists are specializing in one or the other. These include:

• Child and adolescent psychiatry
• Adult psychiatry
• Psychiatry of Old Age (Psychogeriatrics)
• Learning disability
• Behavioral medicine
• Consultation-liaison psychiatry
• Emergency psychiatry
• Addiction psychiatry
• Forensic psychiatry

Some psychiatric practitioners specialize in helping certain age groups; child and adolescent psychiatrists work with children and teenagers in addressing psychological problems. Those who work with the elderly are called geriatric psychiatrists, or in the UK and Australia, psychogeriatricians. Those who practice psychiatry in the workplace are called industrial psychiatrists in the US (occupational psychology is the name used for the most similar discipline in the UK). Psychiatrists working in the courtroom and reporting to the judge and jury (in both criminal and civil court cases) are called forensic psychiatrists, who also treat mentally disordered offenders and other patients whose condition is such that they have to be treated in secure units.

Consultation-liaison psychiatrists in particular have done yeoman service to the cause of mental problems afflicting those treated in general medicine and surgical settings. Research in these areas has led to improved outcomes in a vast variety of patients, and has also led to an increased understanding into psychiatric pathology.

Treatment of mental illnesses no longer involves being shut up in mental hospitals for months and years on end. Most patients can now be treated on out-patient basis with a combination or singly by psychotropic medications and psychotherapy. Occasionally, in-patient treatment is required, but is mostly for weeks rather than months. It is in very rare cases that long-term institutionalization is required. Results of treatment are mostly favorable, and the contribution of social support networks is invaluable.

Psychiatry today is at an exciting stage in its history and development. Everyday, new discoveries enable us to gain new insights. New drugs and new modalities of treatment enable patients to enjoy ever better outcomes and better quality of life. The burden of mental illnesses on societies everywhere is enormous, and the psychiatrist and other allied workers remain committed to the cause of alleviation of the misery caused by these.

The scarecrow

I went to a place by the name of Morni Hills on a "departmental picnic" yesterday, and a beautiful place it is too. While all the rest of my mates were getting spooked out in the hous of horrors, I walked down a short distance to one of the two lakes called pandutal (after the pandavas of the mahabharata) and got this picture. It was only then that I realised that only a few years ago, this place must have been truly magnificient. I glanced up to the denuded hills to see signs of dried up waterfalls which now probably never flow except when it rains a lot, the fields all green with wheat and mustard must have actually been lake bed, now reclaimed for agriculture. Developement, it seems catched up everywhere. High up from the hills, the two lakes are only divided by a small hill, in all probability an island when the lake was bigger and lusher.
When i saw the scarecrow, i initially thought it was a body hanging from the mango tree in the distance, gently swaying in the breeze. There were cries of children at play but there were no where to be seen. other than that, the silence was exquisite and perfect. The whole combination was somehow surreal and in a way even scary. When I look at this picture, I can sometimes get a twinge of that feeling. I think its one of the greatest gift a meaningful picture gives, that is the power to recreate an emotion. Even though imperfect, I know of nothing else that does.
Evereywhere today, the story is the same, shrinking lakes, vanishing forests, no wildlife to speak of. I wonder if we will eventually be in a state to ever save anything before its too late for anything to be saved.
A few days ago, I read an autobiography by Salim Ali, the well known bird watcher. And it was truly fascinating reading. The fall of a sparrow, as it is named as an allusion to his killing a yellow throated sparrow chronicles the state of the magnificient wildlife and forest that we had even fifty years ago. And within these years of independence, we have been spectacularly successful at destroying of most of all that we had. And we are still ready to ruin whatever little that is left.

Convocation

A PGI post after a longish time.
It was the 38th convocation yesterday and everything was spruced up. We even got a new carpeting on the road in quick time and now the path to the new doctor's hostel isnt all that bumpy. There were lots of policemen and policewomen too. Met a few old friends in Khaki from the strike times and also met soome old friends who are not going great guns elsewhere. Last year I had walked down in that gown to recieve my degree too and I know its a lot of fun to put on all that stuff and feel like having done something worthwhile for once.
My congratulations to all those who got their degrees. All the best.

Lunar eclipse of 4th March 07

Lunar eclipse of 4th March 07
Originally uploaded by Pradeep Mahajan.

This is a truly terrific picture taken by a friend, Pradeep Mahajan of the total Lunar eclipse that was visible all over India on the 4th of March, 2007. Pradeep Mahajan also won the rosefestival photography competition and is a noted press photographer. Great shot.

A Sportsman

I played cricket after many years tonight, and made exactly 0 runs and was hit for so many runs in the one over that I bowled that I am ashamed to think about it at this moment in time. Throughout my life, I have been average at a great many things, bad at a substantial minority, and good at precious little. Some people would contest that precious little too. But the one thing I have been uniformly awful at is sports and games. Those may be any kind, Indoor or outdoor, mental or physical, individual or team. You name it, have played it, and been beaten black and blue, been the last to be picked up, been the least valuable player etc etc. And that is not for the want of trying but due to an inherent, effortless clumsiness that has always been a close companion. In such a scenario, the few moments that i might have come out with some credit are truly cherished memories.

Peace- Happy Holi-Day

I was looking through my pictures of Mcleodganj Losar when I came across this one. Instantly, I had that stab of emotion when I saw this lady for the first time in the Tshuglagkhang. There was a sense of peace that arose some yearning in me to be in a peace similar to this.
Considering the fact that I am presently in a state of beer induced bliss myself, I am sure my kins readers will excuse my digressions and indulge me some further.
It is only later that I tried to find what exactly that hand gesture signifies, and as usual googling got me some answers over here. Though I have not been able to find the exactly similar gesture, but it does seem to be a variation on the meditation gesture of a particularly Japanese type. Does anyone have any idea?
On the other hand, I often wondered why people have to travel to "holy" places. And having been to some and pretty sceptical after having been through most, I have come to the conclusion that some places do that when the mind is prepared enough. At the very least, when the mind is free and ready to accept peace and quiet, the 'soul', opens its gates for peace to enter.
I will continue my travels now.
Also to all, happy Holi. Have a good time and play it safe.

Image recovery

This post is to talk about a software I downloaded recently. I had taken some pictures on my D200, and while attaching the memory card to my laptop, had downloaded the images using the windows resource to download which incidentally does not download nikon NEF (RAW) files. As a result, I did not know that i did not have the RAW files until after formatting the CF cards.
Was lost for some time when I googled the net and came upon this site, http://www.cgsecurity.org/. From here I downloaded some software and could get back almost all of my images including the NEF's. This software is free and is wonderful to use. I am not representing whoever runs this site but have written this post only because it worked so well and all other softwares are expensive and have to be paid for.

Alone

I was taking an early morning walk up the Thardoling road in Mcleodganj when I came across a secluded spot just above the Kirti monastery. From here I could see the Kangra valley for miles. Being very tired and having nothing better to do, I sat down on the ground and watched time. There was an occasional Tibetan, dog or mule that passed me by. Many watched me with some mild degree of interest, a few really did not bother. And thats what I like about Mcleodganj, its the degree of freedom that it affords. Come, do your own thing and back you go...into the real world again.
However, paradises have a tendency to get lost. And Mcleodganj is no different. As I sat there, I could see the way the deodhars have been systematically killed, and land illegally occupied, and rules flouted. All for a few quick bucks.
From there, my thoughts drifted away to the past and the turmoil that i have seen. It was a thrill to suddenly realize a feeling of normalcy after a long time. But then as events proved, so much is so fragile. And loneliness is but a footfall away. Gradually, I felt the cool wind take away the pain and the stiffness. And then there was an emptiness that was not at all unpleasant. In fact, it brought back some vaguely remebered emotions.

I came back to life, and to perception, shaken out of my reverie by the raucous crowing of a raven making its rounds high above the Kangra valley. It was looking for breakfast and suddenly I felt hungry too. The light had changed, the mist had cleared from the valley floor. And I could see the trees and houses clearly, another day had begun and people were up and about. The traffic on the road had increased too and there was a constant stream of silk skirts trooping past. So I decided to leave my seat on the grass, and my grandstand view. I stood up, and walked downhill to the Tsuglhakhang to take some more pictures and get some breakfast back at the Chinar lodge.