 Thank you so much for being with us today on this fine Tuesday morning. Asante san and of course my name is Ram Agukko. It's a pleasure being with you on this fine Tuesday morning. And you're just done for the next conversation of the day. If you're just joining us, it's all about Maraskan Sunning Health. And this morning, let's talk about managing cerebral palsy. What is cerebral palsy? In this discussion, if you have any questions in regards to this particular issue, feel free to be part of it. Because joining me in studio is a next but this is none other than Dr. Mahendra Singh. He is a consultant, a spine and a brain surgeon at the Nairobi Neurocare Limited. Welcome Dr. Mahendra. Thank you so much for having me this morning. Yeah, how are you feeling today? It's very nice. Thank you for making that. It's very nice to take out a topic like cerebral palsy. It's a topic that healthcare is still finding its way to creep in, treat more of it. And a lot of practicing doctors are not taking to it. And many people do not understand how to manage patients who are suffering from this. But let's start from the beginning. For somebody who doesn't understand what we are talking about, what is cerebral palsy? So cerebral palsy, as it explains itself, palsy is basically paralysis. So a lot of it comes from some or the whole part of the body or one half of the body can be paralyzed. It usually happens because of the problems during pregnancy. Maybe there was a brain damage during the process of the birth. When the child is taking birth is one of the most difficult journey that one embarks in his lifetime. And cerebral palsy is when sometimes when the baby is trying to come out, the liquid of the mother's amniotic fluid it goes inside. Or it took so much time for the baby to come out or the failure of the cry. Then even once there was a normal birth, the baby didn't cry enough. So the lungs didn't expand, the lungs didn't expand, so oxygen didn't go into the brain. So first few minutes are extremely critical. If even that happened well, then the children sometimes have got a very high jaundice in first few days of life. That can also cause brain damage. But primarily it's a huge brain damage inside the brain cells which are the outermost layer called cortex which is responsible for the general intelligence of human beings. That gets damaged because of this faulty process. Because of this faulty process, especially during childbirth. During the childbirth because what happens inside the baby was in a bag of waters. It's called amniotic fluid. So baby is aquatic at that time. The lungs are totally collapsed and the baby is feeding through the nutrition coming from the umbilical cord from mother to the baby. Now what happens as soon as the bag of water is ruptured and baby comes out, that's when the lungs need to collapse and that's why God has given a mechanism of this sudden crying and it's like parachute opening. So it has to open suddenly and fully. As soon as the baby is out. So the baby's cry is one of the most important things to happen. Dr. Singh, when some Africans see cases like this, there's always this assumption of acasses. There are these myths and misconceptions that maybe you did something wrong. Maybe there's a problem with your family or with your lineage. That is all the case. So not knowing is a status of darkness. So knowledge puts a light on some subject. Things become easier for you to understand. Mechanisms become clearer. And now is a point when you can reason things out. Right? So when we see very ancient scriptures in the caves, we started worshipping sun and water. And because there were times when there were extreme suns and so that kind of human mind which was still trying to understand nature thought that the sun god is angry on you. That's why it's getting so heated. So he's getting water. Right. And when water suddenly came like floods, then they said, what a god is. So let's please them. That's what we used to understand earlier. And I've heard that when Columbus went to United States, there were aborigines there, so they were not giving him access to the land. And because he knew that after sometimes the lunar eclipse is going to come. So he said that, you know, my god is so powerful, it will overpower your gods. Because if you don't do it in next few days, this moon will disappear for a while. And then you will get the diseases. And then they just waited. And then moon just went into the eclipse phase. And then they thought this guy really. That he must have been a very powerful man. So then they gave him access. So that's what is the power of knowledge. So starting from there, if you don't know things, then we start attributing them to something else, some power that we have not seen. And I've seen that even with diseases like Parkinson's disease or movement disorders, in a very rich family here in Kenya, where the lady was in a software business and she was having this problem of a severe Parkinson's disease. But the mother is thinking that, no, this is some black magic. So she doesn't want her to go to doctors. But when she's going to doctors and she's angry because she wants some, you know, people from the tribes to come and do some healing process. So that was the thing. But actually, now we know the mechanisms that brain actually is something that requires a very high concentration of oxygen per minute. The highest. Especially after childbirth. Yes. So what's happens in first one and a half to two and a half years, the brain grows to its maximum capacity. And in a neonate, we call neonate when they're just taking birth immediately after that. So these neonates, their brains are still regenerating a lot. They require constant supply of oxygen. And because there is a failure of the opening of the collapsed lungs, they don't get enough oxygen that they needed. And then there is a damage, just like a stroke happens later. So these kids, you would see that they can express. But mostly it's a mother who can understand. So doctor, I'm trying to understand. So does cerebral palsy have stages of development? And at what point can a mother or a parent know that, you know, my child could be having cerebral palsy? Do we have signs and symptoms? Yeah. So first of all, cerebral palsy is a developing disorder. It keeps on developing. So for example, you're driving, maybe in a race. And your car has some problem. And now the other cars start going past you. So first the faster cars, say you were one among the first ones, first the faster cars are going beyond you. Then even the slower cars are going beyond you. As the race progresses, because now your car is getting more and more slower with time. So there is a comparison with respect to the stage of life and the stage of your body's development. So that's how the brain works also? That's how cerebral palsy emerges with time. So what we are seeing now, we will see more of it as the time passes by. So if we see a spastic kid now, we will be seeing more spastic kid five years later, because the muscles are getting stronger. Now there are different types of cerebral palsy, different grades of cerebral palsy. So we will not go into scientific details of it, but there are mild, moderate and severe, as most of the diseases are classified. So mild cerebral palsy is when, you know, child is appearing quite normal to begin with. Because mostly what happens when the child is there, settling of the breast is one thing, crying, smiling, even smiling comes a little later, which we call as a social smile. So gradually when the milestones are leaving behind, they are not coming. That's when even the doctors can say that there is an onset of cerebral palsy. But doctors at least they can have a high index of suspicion and the child didn't cry well. Okay. If the child cried well, but sometimes even it happens later on, because there are infantile infarcts as well, strokes. So that's very important that, you know, regular visits to pediatrician is important, because sometimes it is so mild that initially a baby is doing just basic things. Yeah. Yeah. Just taking the feed, just Pupu and Susuva and those things. So there are very basic functions and gradually then the baby starts evolving. So that failure of evolution, which we call as the milestones, the developing milestones, which pediatricians very well know. Okay. Some of our hospitals have got very well developed CDC or the Center for Developmental Pediatric Center for Development. So what they do is the developmental pediatrics is something that monitors the child as it's developing from a neonate to infant to a child. Okay. So there are different stages. There are neurological milestones that at certain months the baby should start smiling. The baby should identify the parent, first the mother, then the father, then other family members. Then they start touching things. They start enjoying things, following the objects. Okay. And there's a motor development. They start crawling. First they start turning in the bed. Then they start crawling. Then they start standing. So everything has got a certain respective time. But now with them there is a delay. There is a delay and sometimes it can be so severe there is no development at all. But for parents they may not be able to notice such things. Do you feel like most parents rarely notice these signs until it's too late? Well, even if it's late in cerebral palsy, there is nothing magical that can be done if it was diagnosed earlier. Oh, once it's there? Yeah, because it is damaged already. The brain is damaged. Nothing can be done. So now most we can do is managing these cerebral palsy problems. Okay. When I came here, and then I also realized even in India, there are very few surgeons who are likely to undertake this responsibility. And probably I understand when I get more and more deeper into this that it's kind of depressing for a doctor if they are not able to do anything. Like if you are given a task in which there is very few success rate, then it can be depressing for me particularly. When I started seeing the parents is when more frustration comes to me. Because it requires extreme patience to be with that child. Because when a child is coming, it is it's a huge bunch of expectation is coming with. And mother is thinking something. So, but the first thing is happiness. And the moment you know that now that my child is something that has got a serious issues with development, with intelligence, with so many things, that whole you know the dream thing that collapses. And now they have to go at another level to be to accept that. And surprisingly here, not so much in India, because that's where I have practiced more than 20 years. And I started coming here since 2017. I saw that in a single healthy family, I had three to four cerebral palsy kids. And it requires extreme dedication even to look after one single child. So, are you saying it has nothing to do with the belief that it can be genetically transferred that it's all about genes? No, no, it's not genetically. Nothing about bloodlines or... No, no. In fact, I had a lady I saw very surprising, very encouraging story that there was a lady in India. I met her when she was 60 plus. And she had a mild cerebral palsy. She got married. She gave a childbirth to a healthy child who was a very successful engineer. Wow! And then she had very tight legs. Right? So, she was not able to stand for a very long time. Because of the cerebral palsy? Yes. So, cerebral palsy, I'll come to that, that what are few expressions of cerebral palsy. So, this woman during childbirth, when she was carrying the child, she had to work because the way the conservative families are, the daughter-in-law has to work. She has to carry out all the duties. Then she is not allowed to sit down in front of the seniors. So, she did all of that. Only in the later part, the spasticity kept on increasing, the tightness in the muscle kept on increasing. So much so that her legs were now going... They were getting spread. They were spreading because the outside muscles of the thigh were more tighter than the inside muscles. So, now in the later part of this life, I mean the last part of his life in our 60s, she is now crawling. Wow! Okay? That's what was happening to her. So, as I'm saying that it keeps on growing, because the muscles keep on growing, the strength keeps on growing, so the expression will become different. Different. And before we get to the expressions, just on the same, same discussion that we are having in terms of detection, you're saying once it's there, it's there. And the only thing you can do is to manage it. So, apparently somebody should not say that there is a particular age where it can be manifested. Yes. Is that so? There is no particular age. There is no particular age. It all depends upon severity. And then there is a huge split between the physical abilities of a child and the mental ability. So different. They are different. I have seen a very severely spastic child, and I'll come to what's spasticity, who was topper in the class and topper in the state. Okay? Whole of the county he was the topper. But the only thing is he had his own way of expressing, because the muscles are so tight, which we call them spastic, that he's not able to express. Okay? He had to be tied in the chair. Okay? Otherwise, you know, he used to, everything was very tight. Even the speech becomes tight, because all the muscles, they lose fine control, which comes from the brain. So now I'll come to why there are certain expressions. Yeah, let's talk about the expressions. Yeah. So the way nature made us so-called superior than the animal kingdom, is that we have an extra layer of gray matter. Okay? In the brain. In the brain. Yes. So basically in others, it's more like gray matter inside, and a white matter outside. So gray matter is something from where the function originates. Okay? And it goes to the muscles, to the glands. Okay? Because we have got a sensory system, a motor system, a secretory system, all of that. So animals are more like, you know, without thinking, they're doing the things. Yeah. They can be only trained in a certain pattern. Okay? But in us, there is a huge level of consciousness. There's another level of evolution. Okay? Yeah. And this is because there is an extra gray layer. Yeah. This gray layer lets us think, rethink, redevelop, okay? And redo things. So we can do one thing at one point of time, and then we think, okay, this is not working. Then we sit, we think, what was wrong? What could be done? And then we come with another way, and then we can succeed. That's how human beings could evolve. So just on the same matter, just from out of my head, I didn't plan to ask this, but now that you've mentioned it, is that what can distinguish between somebody who is having a high IQ, a very high IQ from the rest? The critical thinkers, from the non-critical thinkers, those with high EQ as opposed to those who have low IQ? Yeah, more on the EQ side. I usually detest IQ, concept of IQ. That means you're, yes. Okay. I do it. And I'll tell you why with my own example, is that IQ is something you are telling someone as a product that this person comes with this level of intelligence. That's not so true, okay? It all depends upon your conditions, your level of aspirations, okay? Sometimes you suddenly get a smack out of some insult, and then you do things, which are so, you know, superhuman. So how can you say that this person is with this IQ? Meaning you're always, you're always trying to fix the output of a person in a certain way, which can be only intellectual, okay? So like Mr. Kipchoke, who is considered an inhuman or a superhuman? Superhuman, yeah. Superhuman kind of a guy who is running. But does this IQ say that, you know, this guy is going to be a super-runner? Yeah, that does it. It doesn't, yeah. It doesn't, yeah. So for me, when I was a student, and most of the kids, they so don't want to go to the school, okay? And, but there are some who want to go to school. So it all depends upon someone would like to be disciplined very early in life. Someone cannot be. But if you see most of the successful businessmen in the world, they had left the universities. So I mean, so that's why I say IQ is not great. It's not, yeah. And EQ is something which should be, you know, because EQ is a basis of why for everything in life. Yes. Why you want to do it. The emotions. Yes. Okay. So if someone is poor, he wants to be rich. For a middle-class education is the best tool to get from point A to point B, where we consider B is higher. Okay. So for them, it's more important. Right. So EQ is something which is more important. But this is the brain because that's consciousness. Okay. And I have seen when sometimes I have seen patients coming to me in my practice. They live in up country, older people. And there's a young boy who is rich, smart, who is here. But you see more wisdom in the guy who is living with low education in up country. So someone may even argue about how clever a person can be. For somebody who failed and did not succeed in academics, who is a father, will they pass on those traits to their son? And will they also have feelings? So those are false blueprints that we give to our children. Okay. And which should never be done because there is so much of recombination happening with the genetic material of parents and a new baby is coming. You may have siblings. And they all may be different in different capabilities. Some can be fantastic cook. Some can be fantastic in mathematics. The only thing is that you need to encourage them that you can be great in everything. Every brain develops in its own unique way. Exactly. Everybody. So all right, let's go back to the expressions. If we go back to cerebral palsy, the most beautiful thing that I find is that particularly mothers because I think mothers are the highest being on this planet. Me too. Probably everyone because you know, mother is something divine. So they are able to understand their children, their needs, their intelligence, everything, even when the child is not able to speak or there for us. That child may be expressing in a very, very incoherent way. It's something that you can't even understand. Many of them, they can just within a look a few seconds, they would say this child is retarded. Many do this. I mean, and then if these kids go to normal schools and I don't know how it happens, but children also have their own level of cruelty. If you go to school, then only realize that, you know, we say children are so innocent. But you leave children among themselves. They become cruel to each other. They are pushing each other. They are, I got a girl who got some abnormal moments because of extreme stress at the home. And then she's like shaking. And then this was a COVID time. And children are asking her, is this COVID? Are you going to die? If you're going to die, don't sit next to me. So, you know, I mean, someone having a bad family life is also getting a bad life in the school. So, but those mothers are able to see through all those disabilities of expression. They're able to understand. And I've seen whatever they are speaking in whatever way they can, they make sense of it. And actually they can make in their minds, they make complete sentences. Now, I'm looking at managing it. Just a few tips to a parent watching you today. So, before I do that, cerebral palsy comes with broadly two subsets of cerebral palsy. One is flaccid or floppy child. All the muscles are very loose. They're not able to sit. Anything you do, they just fall. They just fold into themselves. It's not a problem. That's a flaccid paralysis. No, it's all because of the muscles. So, as I was saying, that all this cortical layer that we have, that extra layer, which gives consciousness is also the one which is giving us extreme muscle control. Okay. So, from here, the muscle fibers, they descend down through the spinal cord, and then they express into the body through this spinal nerves. They finally go to the muscles. And muscles behave the way we want, like I'm shaking my hand for expression. So, all of this comes from a very complex nervous system, but one of them is a motor system. So, there is a specific area in the brain which is originating all these motor activities. So, there are premotor areas which plan it, and then there is a motor area which executes it. But when this motor area is sending the signals down with the fibers, it's also sending a signal for fine control. So, our muscles have got a certain tone. Tone is something which is, we are not too tight, we are not too loose. If you are too loose, we become floppy, we can't stand. If you are too tight, we become spastic. So, in cerebral palsy, this balance is either this side or that side. So, if it is too loose, then the baby becomes floppy. If it is too tight, the muscles become so tight that even the joints start coming out of, I have seen hip joints coming out of the, you know, this femur, the thigh bone comes out of the joint, and it's lying under the skin because the muscles are so tight. That is extremely painful. And the problem with these kids is that they are not even able to express that they are in pain because of extreme sudden, you know, and then just like a tsunami in a water world. There is a tsunami of signals that keeps going in them. So, they, anyways they come up with abnormal sounds, which is even if they are lying down with no problem, the abnormal sounds they keep coming. Because even the vocal cord is a muscle. So, when they speak, there is sudden blast and then there is a, you know, so they are not able to even speak properly. So, now we don't know when they are in pain and they are not in pain, except that the mother who knows that, you know, my child is in pain. It becomes very difficult for these because the joints are coming out. Muscles are constant state of tightness. So, spastic kids are the ones where we can offer good treatment. Plus, then we see whether the child has got a good intelligence or not. The ability to comprehend is what we would like to see because we may have spastic kids, both of them have got very tight muscles, okay. And we know that there is a, there is a huge, there is a circuit. There is a nervous circuit which goes from brain to muscle, okay. It's a sensory and a motor circuit. So, we know that how a spasticity is produced and how we can break it. Just like an electrical circuit. But if, even if we do that, then the child should be able to take the commands of a physiotherapist or their parents, so that they can work in a certain way, okay. So, physiotherapy is very important. Yeah. So, physiotherapy is important. But what happened because the neurosurgeons were not taking enough interest? It entirely became a physiotherapist's job. And then they became possessive about their patients. So, in India it has happened that when I used to go to them, it's like a muscle becomes a spring, which is constantly getting high-tension signal from brain, okay. You're not breaking that signal, but you're trying to stretch this spring, which is contracting, right. So, doing a physio is good, okay. It's a mainstay. But if you are not doing a neuromodulation, okay, means the way we are modulating the signal going from brain to muscle, you are not doing enough, right. So, there's no point, you know, the kids are stretched by a rope. For a certain time or you are putting them under a splint. When the brain is constantly firing on the muscle to contract. So, unless you modulate that, the physiotherapy will not be very effective. So, the best thing is first to detect early so that we can plan things early. When I came, I came with a lot of enthusiasm. But I realized that sometimes what happens when you're saying that we treat cerebral palsy and a general population cannot understand the difference between treatment, management and cure, okay. They would believe that, you know, once you do the surgery, my child will be cured and the intelligence will become good and everything. And then you say, no, setting up the expectation is one of the key areas of doing surgeries to cerebral palsy kids. So, it became rather slow because I just entered into the canyon space and unless the parent understand and we are on the same page that we are doing, we are only changing the way the muscles are so that they can be better transported. Many times it is so good that sometimes it's only lower half is involved, not upper half is normal. The intelligence is normal, they are the best kids. We call them as great too. So, they have difficulty walking, they have got tight feet. So, they are walking on their toes. You partially cut their nerves which are going to muscle with excessive signals. Now, the muscles are eased out. And the way there is an organization of the muscles in the spinal cord, an irritative segment is also irritating the upper and lower segment in the spinal cord. So, say the calf muscle is very tight, it is also irritating the thigh muscle, it is also irritating the opposite muscle. So, all of these the coordination is not there. Once you reduce the signals of the calf muscle, now even other muscles start behaving well. And when we operate these cases, we are always opening the nerve and then we are testing with electrical signals as to which has got highest signal you cut them. So, sometimes 60 percent, 70 percent, even 80 percent can be cut. Should we pause? Your battery is gone. Life expectancy can be very high in these kids. We have seen kids, even adults several pulses we have seen. Even we have seen that adults even up to 25, 30 years of patients that I have seen. The earlier we are able to operate them, particularly the ones who had good comprehension, then the better physiotherapy can do them. And even with time they start moving better, they start, they can adjust themselves to life much better. So, it is not that the life expectancy is affected. It is again as I would say, my heart really goes to the parents who are looking after these cerebral palsy kids. Because many times this happens that if there is a child like this, the males flee from the family. So many times. And the females are left to take care because they are mothers. They never look back on their child. So, they stay. But the problem is that sometimes these kids are so severely affected. They are not able to, despite being educated, they are not able to go and work. So, I think with the government we can sit and then we need to identify the needs of these mothers who are educated, who are capable, but they are forced unemployed. Because it needs money to treat them. It's very expensive. They are not so comprehensively covered by these schemes. So, unless we understand the whole scenario of cerebral palsy, I mean the family which is going through this, it affects everyone. Sometimes, like a mother can have two normal kids and one cerebral palsy kid, but all the money is draining down because of the medicines, physio and everything. Now, you are not able to take care of those kids who could study. So, it is something that has always haunted me that even if you offer them treatment, we are doing surgeries, but then when they come to a private sector, it always has a cost. A very high cost. So, maybe we are still talking to some people in the government that if they can come with certain schemes for the cerebral palsy. We actually tried to do a lot of surgeries on cerebral palsy in January of 2020, when suddenly Covid came. I saw 250 patients with Lyons Club in Nakuru and they were ready to help us. And then this didn't go through because lockdown happened between the counties. So, we are still hoping, we have formulated certain steps with the Lyons Club and we are also looking for some other people who can come forward, sponsor families for treatment. Then at least we can improve the transport of these kids even if they are very seriously spastic and they are not even able to sit because they are totally straight. Even the legs are straight, hip joints are straight. So, there are actually special carriages for them to transport them straight. We can make them sit. Even that can be a big boon to the families who are suffering. Because now they can be adjusted into a chair. So, they can be transported from one place to another. In one family, we have seen that for 15 years a young parent never gone to a film because theatre, because they didn't want their spastic child to be at home and they are seeing movie. So, once I released this spasticity, that child was able to sit in a cinema theatre. For them that was a, you know, a blessed moment. So, it's sometimes very beautiful to treat cerebral palsy kids, but it's emotionally very draining. Wow! And I wonder how you manage to, you know, get around the disappointment that always comes along. Yeah, so right now I take patients, I'm not operating them right, left and center because it's very important, you know, that for example someone comes and they have money or they have arranged something and then if you operate and they came with an expectation that, you know, our child is going to be fine after the surgery because this doctor is claiming so. And then I have, I become extremely slow. I say, no, you go and think this is what I'm telling you. This is what we are going to do. It's just a palliative care of a child. Yes, there are certain kids who are very brilliant. And, but who just had difficulty walking. Those are the kids we promised that yes, these kids are going to be very fine. Wow! Because the surgeries we are doing at the spinal cord or at the nerve level, sometimes we can discharge the patient very next day. But it's important for them to understand that what exactly is being offered. And just to mention, but a few, maybe you're called to action for the government and any stakeholder that might be interested in dealing with this case or case of cerebral palsy, what would be your call to action and maybe if you have any recommendations that you can give today? Well, the recommendation would be at two levels. One is that we have NHIF here which can take care of it. So, health can be sponsored because like the surgeries that we do are called a selective dorsal risotomy. It's called a SDR and then there is something called as a super selective nerectomies where we go down to the muscles, we explore the nerves into the muscles and we cut them. So, these procedures need to be included in the procedures which are covered by NHIF. And second thing is also to give a economic support to the families, particularly the mothers of the family. So, you know, if something they could be doing at their home while taking care of those kids is something that will give them a kind of employment. Like I have seen in India, because it's a short stay here, this is the third year. In India, we have a program for blinds which has very beautifully parented it down to the village levels where if you're not able to see, they teach them the cane work, you know, the chair making in which there is a special plastic fiber, they are able to weave on the chair. So, those chairs are made by blinds or there are certain jute work that their blinds are trained for. So, these blind people who could not be employed, they can earn money by themselves and then there are NGOs. So, they take these products from the area of production to the market. So, these are the things that the government can do here for the mothers of cerebral palsy kids. Wow. And I have a question from, this is Masi. Masi is asking a question here. What is the difference between cerebral palsy and Down syndrome? Down syndrome is a chromosomal thing as a genetic abnormality, which is not because of a faulty birth process. Of course, I don't know much about why I could see four kids in a otherwise normal pregnancy in a normal family. Why four kids got affected with cerebral palsy? That's a matter of study. And that I've seen only here. It's genetic. Yeah, so that I can say some genetic, because I asked with those mothers that was this birth process faulty with the child cried well, everything was okay. But then why four kids in the same family got cerebral palsy? So, that's something to, but otherwise the cerebral palsy mostly is secondary. I mean, it's after birth you've got a stroke, something happened. Even sometimes a head injury happens to a child and then cerebral palsy happens because there was a, after head injury there was a stroke in the brain. So, a part got damaged. Right? Down syndrome is something which is chromosomal. It comes with a certain set of problems. Okay. So, there's a low mentation. The intelligence is low. There's a certain form of bone deformities which are there. He's not growing well. So, even the spine, we say craniovertible junction, which is a junction of the head and the spine. That's where the defects are. So, those things. But they're not connected to the cerebral palsy and down syndrome. They're not connected. There's one more thing which with parents get confused is autism and cerebral palsy. And cerebral palsy. Yeah. I was also coming there. Autism. Yeah. Autism is a totally different thing. So, babies are born with a different set of perceptions. For example, I've seen a kid who had autism. He is otherwise normal, but the moment you try to extend your affection to him like say you want to touch him, he suddenly becomes violent and hits you. Yeah. So, then I was talking to the parent. They said that he feels, because his perception is so altered, that when the hand is going towards him, he seems a huge hand is coming to me. Which is so, and he gets fearful. And then he reacts this way. Wow. Okay. So, in autism, sometimes someone is just very, he becomes very fearful when he's enclosed space. So, I had autistic child who whenever he goes into toilet, he starts breaking all the tubes, cables, everything is coming out. Okay. But I've also seen in autism, we have also seen a very high level of intelligence. Some of the autistic kids are extremely smart in mathematical capabilities or artistic. One of my friend's son who was a next door neighbor, he had autism. But I saw him when he was just five or six years old. You just give him even a small picture of any car. Yes. Just a side light. Okay. And he would even tell you the details of the engine that has and how many versions of engine that car has. So, that child was autistic. But now he's studying medicine. So, autism is a bit different. So, it's different from cerebral palsy is a whole complex of plus minus abnormal mentation, definitely grossly abnormal muscles of the body particularly. So, the muscular expression is one which is main in cerebral palsy. Either the kids are flaccid or spastic. But is this spastic which we can we can treat? We can modify them? Let me just ask you this before we wrap it up. When we started this conversation, you mentioned one very key issue. During childbirth, you mentioned issues to do with the amnotic fluid and the whole process of oxygen getting into the brain. And you know the umbilical cord. You mentioned that quite a lot of things. Now, it made me wonder, does the doctor have a key role to play when it comes to preventing cerebral palsy especially during that process of child? Yes. So, I would say it's primary healthcare which is where most of the problems happen because majority of people they live in maybe distant or smaller districts, smaller towns or villages. So, primary healthcare is very important because it's the delivery which is more important. Proper delivery of a kid is very important. So, if they are taught well about cerebral palsy that what can happen if we are not doing our job well? The doctors. Not only the doctors like you know we have medical officers. Yes. So, in a developing nation, the periphery will always have less doctors. And childbirth is not something which has started happening now in the past 50 years or 100 years. It's happening for thousands of years. In the animal world, it's natural. And most of the kids are healthy in nature. So, because Kenyan wildlife is anyway so heavily photographed, we can at least tell that you know majority of almost all the kids are coming out normal. So, why it's happening in humanity that we are getting this because now deliveries had been happening for thousands of years. Now we want to do it in hospitals. So, there were always some women who were trained to look after the pregnancy or the delivery part of it. Right? In India it was there. So, there were some designated females who- Midwives. Yeah, midwives. So, they were always there. We just need to give them this modern thing that you know what is happening? What's the importance of crying? Right? All of these things. Well, if the baby is not crying, sometimes you have to tickle, sometimes you have to pet them. Yeah. And they start crying. So, that happens and they become normal because there is a certain standard time in which the baby should cry. So, how many call practitioners need to understand and get training? So, these are the midwives, the nurses in the peripheral hospitals, the medical officers, they should be trained for this. They should be task force against cerebral palsy who should be constantly teaching them the harmful effects of cerebral palsy and what should they do? And they are very basic things. So, I wouldn't blame it to doctors because most of the things are you know when they are happening they suddenly happen in the middle of the night maybe at 3 a.m., 4 a.m. So, it's a doctor on duty or medical officer on duty or nurse on duty or a midwives. They are the basic force for these things. Okay. Okay. Dr. Singh, I want us to bring this discussion to a close and give it up to our final word, a parting shot to Kenyans that are watching you this fine morning concerning cerebral palsy. That's your camera as you bring this to a close just within 30 seconds or so. Thank you so much for having me. I just want to say in favor of cerebral palsy families that many of the things in cerebral palsy can be modified to make your life easier. Particularly, this pasticity can be treated well. These children can be treated well after with physiotherapy. So, just don't rely on physiotherapy. I have found that many parents when I say that you need to show us, we need to map the child's pasticity. They say that no, no, the therapy is already going on. But physiotherapy alone is not helpful because the tightness in the body is coming from the faulty nervous system and we need to break that electrical or neuro electrical circuit. So, once we break the circuit, the physiotherapy suddenly becomes very, very impressive, very fast and the children can actually come to the flow of normal life. Thank you so much, Dr. Mahendra. You're doing a good job. I love the fact that you are also empathetic with your own patients. Yes, more with, there was initial five years. I never charged a cerebral palsy family. You never? No, because I had nothing to offer to them. I was still understanding. Keep doing what you're doing. Because when you are trained, the neurosurgeons are not focusing too much on one of the training part of us. We never get these patients for surgery. So, when they were coming, I mean, they had gone to several places, even people who don't treat them, they claim to treat them and there are alternative therapies and everything. So, they have drained the money anyways. So, when they come, their parents are empty-faced. They are so tired with the world. So, I didn't want to play with those emotions. So, I said, okay, until I started finding that, yes, surgery can be done. There is a hospital in U.S., which is operating children in thousands. So, that's when I said, what are they doing? So, they started closely. So, only till 2017, I operated my first case. Wow. And I saw the results were so quick because you cut the nerves. The child is much better the very next week or the very next day. So, it gave me a lot of satisfaction. Keep doing what you're doing. Thank you so much. And I wish you the best. And you know, it's encouraging to see you having such a heart. Thank you so much for coming today. Thank you. I appreciate your presence. Thank you so much. That is the comment I'm seeing today, ladies and gentlemen. I hope you've learned something. I sure have. And that brings us to the end of this particular discussion on matters concerning managing cerebral palsy. But remember, don't go away. We still have more coming up. You're right here on Why In The Morning. My name is Ram Magukko. It has been a pleasure being with you. Stick around for more coming up after this short break.