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Politics-, वियतनाम और इतिहास का प्रश्न

अमेरिकी राष्ट्रपति बराक ओबामा अभी वियतनाम की यात्रा पर गये थे। वहां उनका भारी स्वागत हुआ। चालीस साल पहले तक जो अमेरिका वियतनाम को नेस्तनाबूद कर देने की लड़ाई में उतरा हुआ था, आज उसी का राष्ट्रपति उस धरती पर जाकर वहां के लोगों से सीधे बात कर रहा है। वह कहता है कि हम दो देशों के अनुभव से दुनिया बहुत कुछ सीख सकती है। सीख सकती है कि लोगों के हृदय बदल सकते हैं। हम अपने अतीत के बंदी होकर नहीं रह सकते।
ओबामा की इन बातों से अनायास ही अढ़ाई साल पहले की हमारी वियतनाम यात्रा की यादें ताजा होगई। उस यात्रा के बाद हमने जो लिखा था, आज उसे मित्रों से साझा करके बहुत अच्छा लग रहा है।
9 अक्तूबर 2013 को हम वियतनाम पहुंचे थे और वही से 17 अक्तूबर 2013 को हमने यह पोस्ट लिखी थी - जनरल जियाप, वियतनाम और इतिहास का प्रश्न। हम जब वियतनाम में थे, तभी वहां वियतनाम युद्ध के किवंदंती नायक जनरल जियाप की मृत्यु के बाद उनके अंतिम संस्कार की सरकारी रश्में पूरी हो रही थी। वह टिप्पणी इस प्रकार थी -
जनरल जियाप, वियतनाम और इतिहास का प्रश्न
आठ अक्तूबर को हम हो चि मिन्ह शहर पंहुचे । चार दिन पहले ही वियतनाम के मुक्ति युद्ध के एक किंवदंती पुरुष जनरल जियाप की १०२ साल की उम्र में मृत्यु हुई थी । सोच रहे थे कि वियतनाम में शोक का माहौल होगा । प्रकृत अर्थ में वियतनाम को पूरी तरह आज़ाद हुए ४० साल भी पूरे नहीं हुए हैं । सन् '७५ में ही तो उसका एकीकरण हुआ, तमाम विदेशी सेनाएँ वियतनाम की धरती से पूरी तरह हटीं और इस नवोदित स्वतंत्र राष्ट्र को शांति से जीने का मौक़ा मिला ।
जनरल जियाप इस राष्ट्र के उन चंद नायकों में एक थे, जिनकी बदौलत तक़रीबन दो सौ साल बाद वियतनाम विदेशी सैनिकों के जुएँ से पूरी तरह आजाद हो पाया था । ख़ास तौर पर दियेन बियेन फू की जिस लड़ाई में दुनिया के इतिहास में पहली बार गोरों की किसी सेना को ग़ैर-गोरों की सेना के हाथों लड़ाई के मैदान में धूल चाटनी पड़ी थी, उस लड़ाई में फ़्रांसीसी सेना के ख़िलाफ़ वियतकांग के सैनिकों की कमान जनरल जियाप के हाथ में ही थी ।
'बर्फ़ में ढंके ज्वालामुखी', हो चि मिन्ह के शब्दों में 'युवती की तरह ख़ूबसूरत' जनरल जियाप का एक और नाम था - लाल नेपोलियन । माओ के गुरिल्ला युद्ध में दीक्षित जियाप जानते थे कि ज़मीनी लड़ाई में व्यापक जनता के सहयोग से अधुनातन सेना के भी छक्के छुड़ाये जा सकते हैं । हांलाकि तब तक द्रोण की तरह के आकाश से निशाने पर अचूक वार करने की तकनीक आज के जितनी विकसित नहीं हुई थी ।
दियेन बियेन फू उत्तर-पश्चिम वियतनाम की घनी पहाड़ियों के बीच किसी कटोरे जैसी घाटी है, जिसे फ़्रांसीसी सेना ने उसके पहाड़ी घेरे की वजह से ही अपने लिये सबसे सुरिक्षत समझा था । उन्हें यक़ीन नहीं था कि इन पहाड़ों को चीर कर कोई उन पर हमला कर पायेगा । द्वितीय िवश्वयुद्ध में जापानियों ने यहाँ एक मज़बूत हवाईपट्टी बनाई थी, और फ़्रांसीसियों को इस पट्टी पर भी बहुत भरोसा था कि कुमुक और उसके लिये रसद को पंहुचाने में उनको कोई परेशानी नहीं होगी ।
लेकिन जियाप ने कहा कि जब बकरी इन ऊँची पहाड़ियों के शिखरों पर चढ़ सकती है तो आदमी भी चढ़ सकता है । और यदि एक आदमी चढ़ सकता है तो हज़ारों की फ़ौज भी चढ़ सकती है । गुरिल्ला युद्ध के इन बुनियादी सोच के साथ जियाप ने शत्रु को औचक पकड़ने की नेपोलियन की रणनीति को जोड़ा । पहाड़ों से लेकर घाटी तक खंदकों का जाल बिछा कर फ़्रांसीसी सेना के बिल्कुल निकट तक घेरेबंदी कर ली और जब नियत समय पर हल्ला बोला तो फ़्रांसीसी सेना के बेहतर हथियार, अमेरिकी एम-२४ टैंकों के परखचे उड़ते दिखाई दिये । दियेन बियेन फू में पराजित फ़्रांस वियतनाम छोड़ कर जाने और १९५४ के जेनेवा कांफ्रेंस पर हस्ताक्षर करने के लिये मजबूर हुआ ।
सामरिक नेतृत्व के अलावा जनरल जियाप वियतनाम की कम्युनिस्ट पार्टी के सर्वोच्च राजनीतिक नेतृत्व के भी अंग थे ।
ऐसे जनरल जियाप की मृत्यु पर पूरे वियतनाम में शोक के माहौल के बारे में हमारा अनुमान ग़लत नहीं था । लेकिन हो चि मिन्ह शहर में ऐसा कोई वातावरण न देख कर दूसरे दिन हमने मेकांग डेल्टा की यात्रा के अपने टूरिस्ट गाइड थामस से बात छेड़ दी । जियाप के शोक की बात सुनते ही उसने बताया कि अब तक उनके प्रति श्रद्धांजलि का कार्यक्रम हनोई में चल रहा था । अगले दिन, अर्थात १० अक्तूबर से १२ अक्तूबर तक हो चि मिन्ह सिटी में चलेगा । इस दौरान शहर के रीयूनिफिकेशन प्रासाद में उनकी तस्वीर पर बड़ी संख्या में शहर और गाँव के कतारबद्ध लोग फूल चढ़ायेंगे । इसके बाद हनोई में उनका अंतिम संस्कार किया जायेगा ।
थामस से बात करने से पता लगा कि वह एक पढ़ा-लिखा, राजनीतिक तथ्यों का जानकार नौजवान है । उसने ट्रैवलिंग के पेशे में स्नातक किया है, और इसी नाते अपने देश के इतिहास से जुड़े तथ्यों की पूरी जानकारी रखता है । इसीलिये और विषयों पर भी बात शुरू हो गयी । मैंने उससे पूछा कि वियतनाम पर अमेरिकियों ने जो ज़ुल्म किये, उनकी कल्पना भी नहीं की जा सकती, फिर भी अमेरिका ही वियतनाम में अधिक से अधिक निवेश कर रहा है और यहां की सरकार भी उसका सबसे अधिक स्वागत करती है ।
हमने चीन-वियतनाम संबंधों और १९७९ में इनके बीच के सीमा-संघर्ष की बात भी उठाई ।
एक शैलानी से १९७९ के चीन-वियतनाम संघर्ष की बात सुन कर थामस बेहद हैरान होगया।
उसने कहा, हम वियतनाम के लोग भी कभी उस घटना का ज़िक्र नहीं करते । हमारे लिये १९७५ ही युद्ध का अंतिम इतिहास है । इसके साथ ही उसने यह जोड़ा कि वियतनाम सरकार की यह साफ़ राय है कि इतिहास को सम्मान के साथ बंद कर दिया जाना चाहिए । ' Close the history with respect.' इतिहास के प्रति पूरा सम्मान है, लेकिन उसे वर्तमान पर बोझ नहीं बनने देना चाहिए । अर्थात इतिहास की सीख और शिक्षा का मान होने पर भी वह एक बंद अध्याय है ।
हो चि मिन्ह शहर में देखे युद्ध के अवशेषों के संग्रहालय और जनरल जियाप की कीर्तियों के प्रति वहाँ के लोगों के गहरे सम्मान के बावजूद आज वियतनाम युद्ध की स्मृतियों से कोसों आगे निकल चुका है । पूरे वियतनाम में चल रहा आधुनिक निर्माण का महायज्ञ भी इसी सच्चाई का बयान कर रहा है ।
हमारे जैसे अति प्राचीन इतिहास के तमाम अवशेषों के बोझ से दबे राष्ट्र के लिये भी ससम्मान इतिहास की विदाई की इस छोटी सी बात का क्या कम महत्व है ?
इस पोस्ट पर कई मित्रों ने टिप्पणियां की थी लेकिन उदय प्रकाश जी की टिप्पणी तीखी और विस्तृत भी थी। उन्होंने लिखा -
Uday Prakash - "लेकिन समस्या यह भी है कि हाल फिलहाल (१ ९ ७ - ७ ९) का विएतनाम जैसा इतिहास हमारे पास नहीं है . फिर ग्लोबल कार्पोरेट एकानामी गरीब-वंचित लोगों को , भले ही विकास के ज़रिये लूट और संहार के माध्यम से , बेहतर आर्थिक सुविधा, चैरिटी और चांस, लाटरी, अपराध और जुए से श्रम-मुक्त कमाई मुहैय्या करती है , जो पुरानी समाजवादी व्यवस्था नहीं कर सकी, इसलिए इसे फिलहाल बेहतर माना जाने लगा है. इस 'बेहतरी का भ्रम' वे लोग और फैला रहे हैं, जो पुरानी अर्थ-व्यवस्था में 'मध्यवर्गीय' और इस नयी अर्थ-व्यवस्था में 'नव-अमीर' हो चुके हैं. ट्रेवेल एजेंसी चलाने वाले लोग, जैसा थामस है या काल सेंटर्स में काम करते एम् एन सी के युवा जिस सर्विस क्लास से आते हैं , वह पुराने मज़दूर वर्ग का नया अनुवाद नहीं है.
फिर आपने एक जगह यह लिखा है :
' हांलाकि तब तक द्रोण की तरह के आकाश से निशाने पर अचूक वार करने की तकनीक आज के जितनी विकसित नहीं हुई थी '
इसका आशय समझ में नहीं आया. क्या अगर ड्रोन की तकनीक उस समय होती , तो क्या जन . जियाप की अगुआई के बावजूद विएतनाम युद्ध हार जाता ?
अभी का उदाहरण लें. अफगानिस्तान में ड्रोन के इस्तेमाल के बावज़ूद अमेरिकी-नाटो फौजें वापस लौट रही हैं . अफगानिस्तान एक दूसरा उदाहरण है, जिसे अभी तक कोई कोलोनियलाइज नहीं कर सका. ब्रिटेन, रूस और अब अमेरिका .
आज सुबह ही अमेरिका के एक दोस्त से बात हो रही थी . शट डाउन इसीलिए है कि 'विकास' और 'बाज़ार' का रास्ता भयावह आर्थिक विषमता और सामाजिक असंतुलन के हालात पैदा कर रहा है. चाहे ओबामा हों या राहुल या मोदी या कोई कम्युनिस्ट, आज गरीबों की बात करने, उनके पक्ष में बोलने के लिए सभी मज़बूर हैं. ..और अगर इतिहास का अंत कहीं हो रहा है , तो यही वह जगह है, जहां पहले के लेफ़्ट और राइट के बीच की विभाजक रेखा धुंधलॆ हो चुकी है. बल्कि मिट चुकी है"
इसके साथ ही उदयप्रकाश जी ने यह आग्रह किया था कि
Uday Prakash Arun Maheshw ji ..is bahas ko aage baDhaayaa jaaye ..!
हमने भी उन्हें लिखा - बहुत ज़रूरी बातें आपने उठाई है । इन पर पूरी गंभीरता से चर्चा होगी । आज हम लौट रहे है ।
इसके बाद ही फिर कोलकाता लौट कर 20 अक्तूबर को हमने लिखा -
"उदय जी,
‘जनरल जियाप, वियतनाम और इतिहास का प्रश्न’ पर आपकी तीखी और सार्थक टिप्पणी के लिये धन्यवाद। खास तौर पर आपका आग्रह कि ‘इस बहस को आगे बढ़ाया जाए’ और भी अच्छा लगा।
फेसबुक का अर्थ ही है दूरदराज बैठे मित्रों के साथ एक जीवंत सार्थक विमर्श, एक वर्चुअल गोष्ठी। लेकिन अक्सर सुचिंतित टिप्पणियां भी ‘समझदारों’ की लाइक्स और ‘उत्साहियों’ की अजीबो-गरीब, आशय-खोजी नोक-झोंक और फब्तियों से आगे नहीं जा पाती। अनोखे प्रकार के उकसावेबाजों की धमाचौकड़ियों का नजारा दिखाई देने लगता है। फिर भी, आश्वस्ति की बात यह है कि इस पूरी अराजकता में भी एक व्यवस्था है; इसके जरिए मुद्दे की बात दूसरे किसी भी माध्यम की तुलना में कम दूरी तक नहीं जाती है।
बहरहाल, अपनी टिप्पणी में उठाये गये विषयों पर बहस को आगे लेजाने का मेरा आग्रह भी किसी से कम नहीं है। इसलिये और भी क्योंकि लेखक हमेशा प्रचारक नहीं होता। वह हमेशा किसी विमर्श का अंशीदार ही हो सकता है।
ट्रैवल गाईड थॉमस की बातों में एक नये ‘उपभोक्ता’ की लिप्सा की छाया देखकर आपका बरसना खास तौर पर बहुत प्रिय लगा। लेकिन ‘Close the history with respect’ वाली उसकी बात का मेरे लिये बिल्कुल भिन्न संदर्भ था। मेरे दिमाग में वियतनाम और समाजवाद के अलावा बौद्ध धर्म का तर्कप्रधान और मध्यममार्गी पहलू भी काम कर रहा था। बुद्ध का एक प्रमुख कथन की धर्म का बेड़े की तरह इस्तेमाल करो, पार उतरने के लिये न कि उसे बोझ बना कर ढोने के लिए।
‘‘धर्म कोलोपम है। यह निस्तार के लिये है, ग्रहण के लिए नहीं। इसीलिये जो ज्ञानी है, उनको धर्म का परित्याग करना चाहिए, अधर्म का भी।‘‘
अंध-परंपरा से मुक्त निरीक्षण के लिये प्रेरित करने वाली नैतिकता और आध्यात्मिकता की तर्कसम्मत और हृदयग्राही व्याख्या ही बौद्धों की शक्ति थी जो मार्क्सवादियों को भी आकर्षित करती रही है। आनंद को कहे बुद्ध के अंतिम शब्द थे : ‘‘सब संस्कार अनित्य है। अपने निर्माण के लिए बिना प्रमाद यत्नशील हो। तुम अपने लिए स्वयं दीपक हो। ‘अत्तदीपा विहरथ‘ - दूसरे का सहारा न ढूंढ़ो।‘‘
उदय जी, वियतनाम का अपने ‘पुनर्निर्माण में बिना किसी प्रमाद’ के लगने और ‘इतिहास को ससम्मान विदा करने’ की थॉमस की उक्ति को हम अपनी जिद से खारिज नहीं कर सकते। बौद्ध धर्म तापसों का धर्म नहीं है। दुनिया ने आधुनिक तापसों का एक सबसे विभत्स रूप कंबोडिया के पौल पॉट में देखा है।
अब हम दूसरी बात पर आते हैं - ‘‘हांलाकि तब तक द्रोण की तरह के आकाश से निशाने पर अचूक वार करने की तकनीक आज जितनी विकसित नहीं हुई थी।‘‘
आपने लगभग क्षेपक की तरह, कुछ अवांतर ढंग से ही आए इस वाक्य को बहुत सही पकड़ा है। मैं जानता हूं कि यह वाक्य अनायास ही नहीं लिखा गया था। बिल्कुल आशयपूर्ण था और आपने एकदम सही, इससे हमारे आशय को साफ करने की मांग की है।
जहां तक वियतनाम की मुक्ति युद्ध में जीत अथवा हार का सवाल है, इस वाक्य से उसका कोई संबंध नहीं है। हम उत्तर-औपनिवेशिक काल में रह रहे हैं। जब दुनिया में कहीं भी उपनिवेशवाद कायम नहीं रह सका, मुक्ति की आकांक्षा का दमन नहीं हो सका तो फिर वियतनाम में क्या होता !
यहां संकेत सिर्फ युद्ध के खास-खास तरीकों की सीमाओं और संभावनाओं की ओर है। इसका प्रमुख आशय आज के समय में गुरिल्ला युद्ध के रास्ते की सीमाओं की ओर संकेत करना है। इस बारे में अफगानिस्तान का आपका उदाहरण सही नहीं लगता। इराक को तबाह करके अमेरिका लौट गया, तो इसे युद्ध के मैदान में अमेरिका की पराजय नहीं कहा जा सकता। भारत के माओवादी ‘तापसों‘ की रणनीति का भी एक सवाल है।
हमने अपनी टिप्पणी में कहा है कि दुनिया के इतिहास में पहली बार युद्ध के मैदान में गोरों की सेना यदि कहीं गैर-गोरों के हाथों पराजित हुई तो वह वियतनाम है। इसका अर्थ यह भी नहीं है कि दुनिया में और कहीं राष्ट्रीय मुक्ति संघर्ष नहीं हुए या उपनिवेशवादियों को उपनिवेशों को आजाद करके भागना नहीं पड़ा। किसी भी रणनीति की सफलता देश-काल की परिस्थितियों, इतिहास और भूगोल के भी सवालों से निरपेक्ष नहीं हो सकती।
इन तमाम बातों के बाद भी आपकी यह बुनियादी चिंता कि विकास से वास्तविक तात्पर्य क्या है, पूरी तरह जायज है और इसपर हमें आगे खुल कर बात करने की जरूरत है।
अमेरिकी ‘शट डाउन’ का प्रसंग एक भिन्न प्रसंग है। 17 दिन बाद उनकी इस आंतरिक राजनीतिक समस्या का समाधान होगया है। चूंकि मामला अमेरिका का है, जहां घटने वाली हर चीज के अन्तर्राष्ट्रीय प्रभाव होते हैं, इसीलिये इसपर इतनी बात हो रही है। लेकिन अकेली इस घटना ने अमेरिकी जनता के सामने उनके सिनेटरों की पोल खोल दी है। स्थिति यह बतायी जा रही है कि लोग इस मामले में अपने सिनेटरों के चरित्र को देख कर यह कह रहे हैं कि इनमें से अधिकांश को आगामी चुनाव में छांट कर बाहर कर देना चाहिए। हेल्थ केयर का सवाल अमेरिकी मतदाताओं के लिये एक बेहद संवेदनशील प्रश्न है। इसपर एक सैद्धांतिक रुख अपना कर ओबामा ने निश्चित तौर पर अपने विरोधियों को बुरी स्थिति में डाला है।"
आज ओबामा की वियतनाम यात्रा और उनके भाषणों के संदर्भ में फेसबुक पर अपनी पोस्ट और उस पर हुई थोड़ी सी बहस को स्मरण करना अच्छा लग रहा है। उम्मीद है, मित्रों को भी यह सार्थक लगेगा।
साभार अरुण महेश्वरी 
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Medical- Science News-(source- nature journal)

Medical research: Time to think differently about diabetes

New guidelines for the surgical treatment of type 2 diabetes bolster hopes of finding a cure, writes Francesco Rubino, but long-standing preconceptions must be put aside.

Subject terms:

UIG/Getty
Surgery can be an effective treatment for type 2 diabetes.
Clinical guidelines published this week1 announce what may be the most radical change in the treatment of type 2 diabetes for almost a century. Appearing in Diabetes Care, a journal of the American Diabetes Association, and endorsed by 45 professional societies around the world, the guidelines propose that surgery involving the manipulation of the stomach or intestine be considered as a standard treatment option for appropriate candidates. This development follows multiple clinical trials showing that gastrointestinal surgery can improve blood-sugar levels more effectively than any lifestyle or pharmaceutical intervention, and even lead to long-term remission of the disease1.

Related stories

As someone who has been investigating the link between gastrointestinal surgery and glucose homeostasis since the late 1990s (see ‘Surgical breakthrough’), I have witnessed first-hand how getting to this point has required many clinical scientists to put aside long-standing preconceptions. Indeed, the guidelines come nearly 100 years after the first clinical observations that diabetes could be improved or even resolved by a surgical operation (see 'A long road')2. The evidence that surgery can prompt the remission of a disease that has long been considered irreversible could bolster searches for what causes diabetes and even reinvigorate hopes to find a cure. But future progress will require more thinking outside the box.

Surgical breakthrough

In 1925, a report in The Lancet2 described a 'side effect' of a gastrointestinal operation to treat a peptic ulcer. This was the almost overnight resolution of an excess of sugar in the urine (glycosuria) — the chief symptom of diabetes at the time. Similar observations were reported in subsequent decades and became more common after the advent of bariatric or weight-loss surgery in the mid 1950s, which led to more people with diabetes receiving these types of operations. And during the 1980s and 1990s, resolution of diabetes after bariatric surgery was noted on many occasions, including in a landmark report involving more than 120 patients9.
In 1999, while working as a research fellow at Mount Sinai School of Medicine in New York City, I stumbled across a report showing that nearly all people with type 2 diabetes who had undergone a complex bariatric operation (biliopancreatic diversion) had completely normal blood-sugar levels as early as one month after surgery. They had been able to stop taking medication and come off a low-calorie diet. I wondered whether gastrointestinal surgery could influence diabetes directly. If so, surgery could be used to treat diabetes or to understand how it works.
The next day, I persuaded my mentor to seek approval from the institutional review board to run trials in humans. Failing to obtain approval, we turned to rats to investigate whether a modified form of gastric-bypass surgery could directly influence glucose homeostasis. Our experiments confirmed that it could, although it took us more than two years to publish the findings6.
In 2006 and 2007, surgical teams showed that the operation had the same effect in humans10, and other groups began to investigate the molecular mechanisms that might be responsible. On the back of these studies, a multidisciplinary group of leading clinicians and scientists at the first Diabetes Surgery Summit in 2007 reviewed the preliminary mechanistic and clinical data available on the effects of surgery on diabetes and established an agenda for research priorities. The summit inspired the randomized clinical trials that now provide the evidence supporting a role of surgery in diabetes. In September 2015, the introduction of surgery into standard care for type 2 diabetes was formally recommended by the participants of the second Diabetes Surgery Summit1.
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Clinical shift

The number of adults around the world with diabetes quadrupled from 108 million in 1980 to 422 million in 2014 (ref. 3). About 90% of these people have type 2 diabetes — a major cause of kidney failure, blindness, nerve damage, amputations, heart attack and stroke. Fewer than 50% of people with type 2 diabetes control their blood-sugar levels adequately by changing their diet or exercise regime, or by taking drugs.
Bariatric or weight-loss surgery refers to various procedures. Surgeons may, for instance, remove a portion of the person's stomach or divide the stomach into two and reroute the small intestine to the upper part (see 'Gastric bypass'). Since the mid 1950s, people whose body mass index (BMI) is greater than 40 have received bariatric surgery to induce weight loss. Many of these people also had diabetes. The new guidelines advise that such procedures (metabolic surgery) be considered specifically for the treatment of diabetes in people who have not adequately controlled their blood-sugar levels through other means, and whose BMI is greater than 30 (or 27.5 for people of Asian descent). Perhaps more significantly, they also state that the gastrointestinal tract is an appropriate biological target for interventions designed to treat diabetes1.
These recommendations arguably signify the most radical departure from mainstream approaches to the management of diabetes since the introduction of insulin in the 1920s. They are based on findings from a large body of work, including 11 randomized clinical trials conducted over the past decade1. In these studies, most surgically treated people (up to 80% in a recent 5-year follow-up4of a randomized trial) fall into one of two categories. Either their diabetes goes into apparent remission or their blood-sugar levels can be stabilized using reduced medication or exercise and a calorie-controlled diet (see'Big benefits').
Non-randomized studies, involving people receiving surgery and matched subjects treated with standard interventions, suggest that surgery may also reduce heart attacks, stroke and diabetes-related mortality1. And several economic analyses suggest that the costs of surgery (roughly US$20,000–25,000 per procedure in the United States) may be recouped within 2 years through reduced spending on medication and care5.
The effects of surgery on diabetes are dramatic. Yet it has taken nearly a century to unearth them since observations of major improvement or remission of diabetes after surgical operations were first reported2.
Source: Ref. 4
A major stumbling block seems to have been the lack of a plausible mechanism to explain how gastrointestinal surgery is able to resolve the symptoms of diabetes. Numerous surgeries — knee and hip replacements, appendix removal, even bariatric surgery — have been performed for decades without randomized trials confirming that these approaches are more effective than less invasive ones. But surgery explicitly seems to fix what is broken in those instances. However, in the case of diabetes — a systemic disease with dysfunctions involving the pancreas, liver, muscle and fat (adipose) tissue — it has been much harder to imagine what surgery would be able to mend.
The dominant 'adipocentric model' has also been a major conceptual barrier to the acceptance of surgery as a treatment for the disease itself. This model posits that excess fat causes diabetes, either by causing the liver to malfunction or by making other cells resistant to insulin. Because this model predicts that the reduction of fatty tissue, however obtained, can relieve the symptoms of diabetes, weight loss after bariatric surgery has provided a straightforward explanation for the associated remission of the disease.
It was exactly this absence of understanding about mechanism — and the mismatch between observations and mainstream thinking — that delayed the prescription of the painkiller aspirin to people with heart disease in the twentieth century. Clinical observations in the early 1950s suggested that aspirin could prevent thromboses. But large-scale trials to test the drug's ability to prevent heart attacks began only in the 1970s, after experiments had shown that it could inhibit blood clotting.
We now know that the dramatic effects of surgery on diabetes are not just a consequence of weight loss. Changes to gastrointestinal anatomy can directly influence glucose homeostasis6. Over the past decade, efforts to explain the link have identified several potential mechanisms7. For one, surgery seems to alter the amount and timing of the secretion of gut hormones, which in turn influence insulin production. Experiments also suggest that surgery can increase the production of certain bile acids that make cells more sensitive to insulin, or increase the uptake of glucose by the gut cells themselves, thereby lowering blood glucose levels. Surgery-induced changes to the composition of the gut microbiota and to the efficiency of intestinal nutrient sensing also seem to contribute. This is the process by which cells lining the gut detect certain nutrients and send neural signals to brain centres involved in the regulation of glucose metabolism.
SSPL/Getty

A change of mind

Capitalizing on these latest insights about type 2 diabetes will require a shift in mindsets across the broad spectrum of care and research.
The high upfront costs of surgery and the specialized staff and medical centres needed to deliver it make surgery an unlikely solution for the ongoing epidemic. Rates of diabetes are rising rapidly in low- and middle-income countries3, where surgery is not likely to be available for most patients. But if handled the right way, the inclusion of surgery as an option could influence diabetes care as a whole.
Currently, many people with diabetes and obesity grow disheartened after trying one treatment after another to no avail. Just knowing that through surgery the possibility of major improvement and even remission exists may be empowering to some. Also, to identify those people for whom surgery may be appropriate, providers will first need to be confident that other options have failed1. So both patients and providers may be encouraged to approach conventional treatments with more determination and rigour.
The broad endorsement of surgery as a treatment option should also inspire fresh approaches in research. Researchers and clinicians are already trying to mimic the effects of gastrointestinal surgery using less-invasive interventions. For instance, experiments originally conducted in rats, and various studies in humans, have shown that blocking intestinal signalling from the duodenum or upper small intestine can alleviate the symptoms of diabetes6.
One approach aims to do this by means of a tube inserted into the intestine. Designed to prevent contact between nutrients and the lining of the upper small intestine, this tube mimics the effects of a surgical bypass. The device has been approved for clinical use in Europe and Australia. Another approach involves passing a balloon-tipped device through the mouth and down into the duodenum, where it is filled with hot water to burn (ablate) the cellular lining. A clinical trial of the device is currently in the recruitment stage in Europe. Pharmacological interventions that target gastrointestinal mechanisms of metabolic regulation are also being investigated.
The ability of gastrointestinal surgery to influence glucose homeostasis and clinically reverse diabetes suggests that the disease might be explained, at least in part, by a fault in the mechanisms through which the gut regulates metabolism8. Testing this hypothesis could provide insights about ways to prevent and even cure diabetes.
Despite the compelling results of clinical trials and experimental work on nutrient–gut signalling mechanisms, shifting diabetes' image as an incurable, hopeless condition caused by excess fat will still require some imagination. Albert Einstein once said that imagination is more important than knowledge. The story of surgery and diabetes shows how important it is to have both.
Nature
 
533,
 
459–461
 
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doi:10.1038/533459a
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References

  1. Rubino, F. et al. Diabetes Care 39, 861–877 (2016).
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  2. Leyton, O. Lancet 206, 1162–1163 (1925).
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  3. NCD Risk Factor Collaboration Lancet 387, 1513–1530 (2016).
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  4. Mingrone, G. et al. Lancet 386, 964–973 (2015).
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  5. Klein, S., Ghosh, A., Cremieux, P. Y., Eapen, S. & McGavock, T. J. Obesity 19, 581–587(2011).
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  6. Rubino, F. & Marescaux, J. Ann. Surg. 239, 1–11 (2004).
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  7. Dixon, J. B., Lambert, E. A. & Lambert, G. W. Mol. Cell. Endocrinol. 418, 143–152 (2015).
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  8. Rubino, F. Diabetes Care 31, S290–S296 (2008).
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  9. Pories, W. J. et al. Ann. Surg. 222, 339–350 (1995).
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  10. Cohen, R. V., Schiavon, C. A., Pinheiro, J. S., Correa, J. L. & Rubino, F. Surg. Obes. Relat. Dis. 3, 195–197 (2007).
    Show context

Author information

Affiliations

  1. Francesco Rubino is professor of metabolic and bariatric surgery at King's College London and consultant surgeon at King's College Hospital, London, UK. He is an organizer of the Diabetes Surgery Summit.

Competing financial interests

F.R. declares the following interests. Scientific advisory board: NGM Biopharmaceuticals. Consulting fees: Fractyl; Covidien/Medtronic. Speaker honoraria: Sanofi, Ethicon, Janssen. Research funding: National Institute for Health Research (NIHR)

Corresponding author

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Archaeological-science news(Nature-Journal)

NATURE | NEWS FEATURE

The secret history of ancient toilets

By scouring the remains of early loos and sewers, archaeologists are finding clues to what life was like in the Roman world and in other civilizations.

Ethel Davies/Robertharding/Getty
Loo with a view: an ancient Roman public latrine in the ruins of Timgad, Algeria.
Some 2,000 years ago, a high-ceilinged room under of one of Rome's most opulent palaces was a busy, smelly space. Inside the damp chamber, a bench, perforated by about 50 holes the size of dinner plates, ran along the walls. It may have supported the bottoms of some of the lowest members of Roman society.
Underwater archaeology: Hunt for the ancient mariner
Today, the room is shut off to the public, but archaeologists Ann Koloski-Ostrow and Gemma Jansen had a rare chance to study the ancient communal toilet on the Palatine Hill in 2014. They measured the heights of the benches' stone base (a comfortable 43 centimetres), the distances between the holes (an intimate 56 cm), the drop down into the sewer below (a substantial 380 cm at its deepest). They speculated about the mysterious source of the water that would have flushed the sewer (perhaps some nearby baths). Graffiti outside the entryway suggested long queues, in which people had enough time to write or carve their messages before taking a turn on the bench. The underground location, combined with the plain red-and-white colour scheme on the walls, implied a lower class of user, possibly slaves.
In 1913, when Italian excavator Giacomo Boni excavated this room, toilets were an unmentionable topic. In his report, he seems to mistake the remains of the holey benches for something much more sensational: part of an elaborate mechanism that, he speculated, would have pumped water and provided power for the palace above. Boni's prudish sensibilities wouldn't let him recognize what was before his very eyes, says Jansen. “He couldn't imagine it was a toilet.”
Evidence mounts for interbreeding bonanza in ancient human species
A century later, toilets are no longer such an unacceptable research topic. Koloski-Ostrow, at Brandeis University in Waltham, Massachusetts, and Jansen, an independent archaeologist based in the Netherlands, are among a growing number of archaeologists, infectious-disease specialists and other experts who are shining light on the lost loos of history, from ancient Mesopotamia to the Middle Ages, with a particular focus on the Roman world.
Their investigations have provided a new way to learn about the diets, diseases and habits of past populations, especially those of the lower classes, which have received scant attention from archaeologists. Researchers have inferred that Roman residents ventured into their toilets with some trepidation, in part because of superstition and also because of very real dangers from rats and other vermin lurking in the sewers. And although ancient Rome is famous for its sophisticated plumbing systems, modern studies of old excrement suggest that its sanitation technologies were not doing much for the residents' health.
“Toilets have a lot to tell us about — far more than how and where people went to the bathroom,” says Hendrik Dey, an archaeologist at Hunter College in New York.

Queen of latrines

Although studies of ancient latrines are no longer off limits, they do take a certain amount of fortitude. “You have to have a very strong sense of self and of humour to work on this topic because one who works on it is going to get ribbed by friends and enemies,” says Koloski-Ostrow. She got started on the topic nearly a quarter of a century ago, when classicist Nicholas Horsfall called her over in the library at the American Academy in Rome. “Latrines. Roman latrines,” he whispered conspiratorially. “No one has done them properly.” She took up that challenge, and now, she says, “I am known widely on my campus as 'the queen of latrines'.”
UNC Department of Classics
One of the first known toilets that was flushed with water is at the palace at Knossos on the island of Crete.
The invention of some of the first simple toilets is credited to Mesopotamia in the late fourth millennium bc1. These non-flushing affairs were pits about 4.5 metres deep, lined with a stack of hollow ceramic cylinders about 1 metre in diameter. Users would have sat or squatted over the toilet, and the excrement would have stayed inside the cylinders with the liquids seeping outwards through perforations in the rings.
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Until recently, scholars had little interest in these toilets, says archaeologist Augusta McMahon at the University of Cambridge, UK. “Archaeologists in Mesopotamia have looked at them like, 'this is a problem: it's a pit that's cut into the stuff I'm really interested in'.” As far as she knows, no one has carefully excavated a Mesopotamian toilet yet — something she's hoping to do when she finds a good candidate and funding.
Mesopotamians themselves also seemed to show little enthusiasm for this revolutionary technology. Although the toilets would have been convenient to use, and cheap and easy to install, they were uncommon, says McMahon, who surveyed the number of latrines in different neighbourhoods for a chapter in a book published last year1. “The number of houses that have toilets is very, very low — one out of five or two out of five,” she says. Everyone else probably used a chamber pot or simply squatted in the fields.
So the health benefits of the technology would have been limited, McMahon says. Although the pit toilets would have successfully separated people from their waste — the measure of a good sanitation system because it prevents the faecal–oral spread of disease — studies by the US Agency for International Development say that some 75% of a population must have access before there are widespread improvements in health.
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About 1,000 years later, the Minoans on the island of Crete in the Mediterranean improved the toilet by adding the capacity to flush — although only for the elite. The first known example2 was in the palace at Knossos, says Georgios Antoniou, a Greek architect who has studied ancient sanitation in that country. Water was used to wash the waste from the toilet into the sewer system of the palace.
From there, toilet technology took off. In the first millennium bc, ancient Greeks of the Classical period and, especially, the succeeding Hellenistic period developed large-scale public latrines — basically large rooms with bench seats connected to drainage systems — and put toilets into ordinary middle-class houses. “The society had become more prosperous, and they were dealing more with comfort in everyday living,” Antoniou says.
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Communal toilets at the Roman site, Ostia Antica.
The Romans were unprecedented in their adoption of toilets. Around the first century bc, public latrines became a major feature of Roman infrastructure, much like bathhouses, says Koloski-Ostrow. And nearly all city dwellers had access to private toilets in their residences. Nonetheless, archaeologists know very little about how these toilets worked and what people thought of them, she says. One reason is that in Roman times, few people wrote about toilets, and when they did, they were often satirical, making it hard to interpret their meaning.
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But Koloski-Ostrow and Jansen show that it is worthwhile taking the topic seriously. For a forthcoming book on toilets in the Roman capital, they and some two dozen other archaeologists have analysed more than 60 toilets scattered throughout the city, most of which had not been described before. That includes toilets for guards in the city wall, and a two-person toilet in an apartment block. “I guess it will be news to a lot of archaeologists who have worked on all kinds of Roman buildings that some of these buildings actually had toilet facilities,” Koloski-Ostrow says.
Roman public latrines looked much like their Greek predecessors: rooms lined with stone or wooden bench seats positioned over a sewer. The toilet holes are round on top of the bench, and a narrower slit extends forward and down over the edge in a keyhole shape. These slits probably allowed users to insert a sponge-tipped stick for cleaning. Small gutters often run parallel to the seats along the ground; researchers suspect that people probably washed the sponges in water running through those gutters. There are no signs of barriers between the toilet seats, but people probably had a measure of privacy thanks to their long garments and the limited windows, says Koloski-Ostrow.
Private toilets were different, Jansen says. In residences, commodes were often in or near kitchens, which was practical because they were also used to dispose of food scraps. Although people flushed the toilets with buckets of water, the loos were rarely connected to sewers. When the pits filled up, they were probably emptied, either into gardens or fields outside the town, Jansen says.
Sewers — long thought to be a crowning achievement of Roman civilization — were in fact less widespread than once thought and might not have been very effective, says Koloski-Ostrow. In a book published last year3, she considered whether Roman sewers would have adhered to any of the modern principles of sanitation engineering, including regular aeration and features to control the deposition of solid waste, which would reduce the stench as well as improve flow. To a great extent, the sewers didn't meet the standards. Her own recent explorations of the Cloaca Maxima, the great sewer under Rome, revealed that some channels could get completely blocked with silt in less than a year. At the very least, they would have required regular cleaning — dirty and dangerous work.
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And Roman toilets also had a number of deficiencies. One major problem was that there were no traps — or S-shaped bends — in the pipes beneath toilets to keep out flies. Environmental archaeologists Mark Robinson at the University of Oxford and Erica Rowan, now at the University of Exeter, UK, analysed the well-preserved contents of a closed sewer that was connected to several toilets in an apartment block in Herculaneum, a Roman city destroyed by an eruption of Mount Vesuvius. Among the faecal matter and other rubbish thrown down there, Robinson found lots of fragile mineralized fly pupae. With easy access to human waste, flies could have transferred faecal matter and pathogens to people.
To look at the benefits of ancient sanitation systems, palaeopathologist Piers Mitchell at the University of Cambridge analysed published studies of parasites found at archaeological sites from several eras4. Contrary to his expectations, the prevalence of intestinal parasites such as roundworm and whipworm — which cause dysentery — did not decrease from the Bronze and Iron ages to the Roman period; they gradually rose. That might be because the Romans used human waste as fertilizer, which would have transferred the parasite eggs to food. “Toilets and sewers and things didn't seem to improve the intestinal health of the Roman population,” he says.

Diet details

The practice of throwing kitchen rubbish down toilets was unhygienic for the ancient Romans, but the remnants of that refuse are now a rich source of information. Rowan was surprised by the quality and variability of the foods in the Herculaneum sewer, especially because it was connected to an apartment complex that housed a large number of mostly poorer people. “We always think that anyone non-elite in the ancient world is not eating a very diverse or interesting diet,” she says. But the evidence from Herculaneum shows that people across the class spectrum were eating dozens of different types of food, most commonly figs, eggs, olives, grapes and shellfish. They flavoured their meals with seasonings such as dill, mint, coriander and mustard seeds5. “It would be quite healthy, and they'd be getting all their essential nutrients.”
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Rowan also used the sewer contents to glean insights into the broader food and energy economy. The large amount of kitchen scraps suggested that the residents cooked more at home than previously thought5. From the quantity of fish bones found, she concluded that the regional fish trade was probably much larger than scholars had suspected6. Such discoveries are part of a broader trend in Roman archaeology, says Dey. Until recently, most scholars focused on the monumental structures occupied by elite residents. But attention has shifted to lower down the class ranking. “Roman archaeologists started to realize that you can't understand how a society works if you only study the 1%,” he says. “The study of toilets is part of the broader effort to understand how Roman society worked, which includes — especially — studying how the non-glamorous parts of society worked.”
Luigi Spina/Electa/Mondodori/Getty
The Roman goddess Fortuna (right) was believed to protect latrine users from dangers. An inscription on this fresco from Pompeii warns toilet users to beware.
For Koloski-Ostrow and Jansen, latrines provide a window onto the beliefs of that society. Romans perceived demons everywhere, and some Roman literature refers to ones that lurked in toilets. “The demons can cast a spell on you, and when you have this spell you die or you get sick,” Jansen says.
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The Roman writer Claudius Aelianus tells a story in his De Natura Animalium about an octopus that swam up through a drain in a toilet and ate the pickled fish in the pantry night after night. That story is probably apocryphal, but rodents, insects and other creatures could have lurked in toilets and invaded homes. And excrement-filled water could have flowed upwards during flooding.
Explosive gases might also have been a problem. “You might walk in and actually see a flame burst out of one of those holes because of the methanic gases that built up in the sewer underneath the toilet,” Koloski-Ostrow speculates.
This pervasive fear of toilets could explain the mystery of why there's less graffiti inside public latrines than in the rest of the Roman world, Jansen says. Nobody wanted to spend more time there than necessary. The same fear could also explain why many latrines have small shrines to the goddess Fortuna. Jansen argues that she was thought to protect toilet-users from illness-causing demons, as well as the other bad things that could happen there7.
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More discoveries about ancient lifestyles will come as researchers expand their toilet studies to other parts of the globe. Rowan is studying a site in Turkey, and Mitchell has recently examined evidence from a 2,000-year-old toilet in China. But progress has been slow and archaeologists are not rushing into toilet studies. Although the topic is no longer considered fringe, funding is hard to come by, and Mitchell says that “no one else seems to be that bothered” to work on it. One reason could be that the lack of written sources and the limited physical evidence make it daunting.
But for researchers such as Koloski-Ostrow, the recent work raises all kinds of questions about ancient societies. Did women use public toilets? Were they chatty, social places or silent? What were the foreign influences on Roman toilets, and how did the toilet culture propagate between the capital and the distant states? These questions will be hard to answer, she says, but asking them no longer seems as weird as when she started.
Rowan agrees: toilets have finally gone mainstream. “If somebody finds a latrine now, they know to sample it, to excavate it carefully. They know there's going to be a lot of value in it, as opposed to being, like, oh, it's just a toilet.”
Nature
 
533,
 
456–458
 
()
 
doi:10.1038/533456a
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