Diagnostic technology today is now becoming highly sensitive and specific, such that we are able to detect a disease years before it reveals itself in a patient and starts to cause visual impairment. Dr. Arulmozhi Varman, renowned ophthalmologist who has been at the forefront of utilizing advanced diagnostic technology to improve patient care, elaborates on how science and technology reach out to the patient in delivering appropriate care in a timely fashion.
What does specificity and sensitivity mean in ophthalmology? In the medical field today, tests are just increasing and diagnostic procedures are proliferating. They’re getting better and also expensive. How does a doctor choose a particular procedure? I’m not talking about treatment at all. I’m only talking about diagnosis—it is getting pretty expensive these days. That is when they (the doctors) look at sensitivity and specificity. Sensitivity means the ability of a test to accurately identify a person with a disease or a disorder, and Specificity reveals that a person does not have a disorder. Both should be of a high percentage—before you can pick up a diagnostic procedure and apply it to a particular patient.
True positive is when a person, who undergoes a test, has got a disease and the test accurately diagnoses it. True negative is when a person does not have a disease and the test also confirms it. False positive is when the person does not have a disease but the test has wrongly diagnosed the person; that’s pretty much risky. In the same way, false negative is when a person who has got the disease is diagnosed as not having the disease. We don’t want sensitivity less than 92%. We need to understand this about every diagnostic test and then look at the demographic prevalence of the disorder and apply the test to that particular demographic group. Then you will get better positive results.
Also, we want to have more and more non-invasive tests. MRI is absolutely safe but if you put in a dye to do an angiographic test, then it’s an invasive procedure. When you put a product into the body, there are people who react to it. We want to have more and more tests which are absolutely non- invasive but which can give you results that were obtained only by an invasive procedure.
Three Eye Diseases
Let me discuss about three diseases:
- Glaucoma and
- Diabetic retinopathy
India today has the dubious distinction of having the largest number of diabetics in the world. Unfortunately, we also have a whole lot of diabetic complications. The diagnostic tool that’s common to all of these is something known as optical coherence tomography (OCT). We know CAT scan, which is computerized axial tomography, where we use X rays and get slices. In OCT, we use light itself and this light source can give sections of the eye, just like you would see on a CAT scan or MRI. It gives unbelievable results.
The accuracy here is about three microns. One micron is 1,000th of a millimetre and you can look at the retina which has 10 layers. Normally, to see the 10 layers of retina, you have to have a particular tissue, which is taken from a person who has already passed away. You have to put it into a section and put it under a microscope. Only after this, you can make it out. But with OCT, you can make out the 10 layers one by one.
Each layer has got either cells or nerve fibre bundles. Today, this technology can count the number of cells on the retina and tell you the count per square millimetre, from which you can know if there’s a dropout of cells or the nerve fibres. That’s the level of accuracy we get and it’s totally non- invasive.
The Doppler Effect
When you stand on a railway track, the train comes in with the horn on. As it comes, the tone gets compressed and as it leaves it gets elongated. You can trace a moving object using this Doppler Effect and that’s how we do Doppler of the carotid or the vertebral arteries and find out the blood flow there. Thanks to the ingenuity of human brain, we use the Doppler using light source and you can delineate the blood vessels brilliantly.
There are people who develop the disorder known as keratoconus. Mostly, this is inherited disorder. It comes out in the teens or at a later age. It can be worsened by allergies and by active rubbing of the eye, but otherwise, it can present itself as a natural course of the disorder. To diagnose keratoconus, we have been looking at the eyes sideways or make the patient look down to spot for a funny looking bulge. To be able to catch this bulge on a slit lamp or with the naked eye, the bulge has to be almost one or two millimetres. That means, the disease is already very advanced. That was how it was done when I was doing my PG in the 80s.
There was another way of looking at it. If somebody has a high cylinder power that keeps changing and a poor vision, then you say that person has got keratoconus. This disorder is pretty prevalent in India and in the Middle Eastern countries also.
Now with the OCT, the resolution is three microns. When there’s a 10 micron difference in the thickness of the cornea or by looking accurately at the shape of the cornea, you can catch the disease at a very early stage. It’s a totally progressive one and as it progresses, vision drops and eventually we had to do only keratoplasty. We take out that cornea, use a donor cornea and sew it on. That was pretty much a difficult surgery with not so good outcomes. But now we can prevent this from occurring by doing certain treatments, which will strengthen the cornea and prevent it from becoming weaker and bulging. That’s called Collagen Crosslinking. The diagnostic machine gives raw data. Algorithms had to be developed to get to the diagnosis. So we had multiple groups of scientists working on this to come up with algorithms.
We can get accuracy to the specificity of 98% and sensitivity of 92%. That’s really good. So early diagnosis would help preserving vision and preventing surgical intervention.
From Lasik, by Luck
What made the diagnosis of keratoconus bloom and fructify into something that’s phenomenal is simply because a lot of patients were willing to undergo laser treatment that is Lasik or now SMILE, to remove the glasses using laser. You can do it on a person who is 18 years plus who is wearing glasses and if the person’s cornea is stable and if everything is good, you do a five minute laser procedure and no glasses are needed for lifetime. When they started looking at the cornea very carefully, they started catching keratoconus.
So, unless there’s money in something, the industry does not do any study into a particular pathway. Keratoconus by itself was not a money spinning entity. A research cannot start off unless it is going to be funded. Funding does not come in, unless there’s a future to the product. That is how, keratoconus could be diagnosed as a spinoff from Lasik.
Then let’s come to diabetes. India has the largest diabetic population in the world. The Western literature says that almost 30 to 40% of people with diabetes tend to develop diabetic retinopathy. While the Indian demographic data says the percentage is a little lower, on an average, around 20% of people with diabetes develop retinopathy.
This has to be caught because this is a silent disease. At least in keratoconus, the patient will have blurred vision. Here, it’s absolutely silent. By the time the vision starts to blur, it is too late. Most often, it is very difficult to do anything about the vision already lost and you can prevent further loss of vision by treating appropriately.
Diabetes affects blood flow. Whether it is the eye, the brain, the heart, the foot or the kidney, it is only the blood flow that is impeded at the capillary level and not at the large vessel level. Once that occurs, blood starts to leak out there. New capillaries try to form to overcome the blocked areas but these are not as structurally strong as the normal capillaries. The normal blood vessels start to leak serum, then blood, followed by other complications. They’re not able to supply oxygen to the tissues, in spite of new vessels forming and the old vessels are blocked. That’s the underlying pathology.
The advantage is that the retina is the only place in the human body where blood circulation can be physically observed. This assumes a huge amount of importance. Though we can look at the blood flow and the structure, we won’t know how the blood is flowing through it. We had to inject a dye called fluorescein into the eye and take serial photographs. This is called fluorescein angiography. We were not doing it frequently, because it is an invasive procedure. Some people develop allergy to it and can have even a cardiac arrest sometimes. Though the risk is one in 10,000, still, that’s a risk. It is also not practical to do these tests frequently.
Now we can see the blood flow using OCTA (OCT with angiography), which uses the Doppler principle and light instead of sound. It’s far more accurate and far more details are available. You can do this once in 24 hours, if you wish to, for a patient and it’s absolutely risk free. So we really have a non- invasive procedure, which is brilliantly accurate to diagnose early retinopathy.
Dilemma in Application
Then it comes to how many patients am I going to put on this machine?
Are we going to put every diabetic patient on this? Or are you going to put only people who you think, have some kind of a problem by looking at the patient with the microscope? It is a very difficult question to answer. Then you have algorithms for this. If you have a patient whose sugar is well controlled and he or she has only three to five years of known diabetes history, maybe the chance of development of retinopathy is low. Anybody over 10 years of known diabetes should have this test done every year. That’s no question at all. Anybody between five to 10 years and poorly controlled diabetes, should have this test done every year.
In spite of all that, if I do 10 patients, I’ll probably catch two or three patients with the disease. That means we are doing more procedures than what is probably warranted. That’s how we it look outwardly. But when you do serially on a person every year, you can catch the person’s disease very easily down the line. So this is where cost comes into play. A low end machine with low resolution costs only 75 lakhs and the high end machine will cost 1.5 crores. The patient has to bear the cost. The doctor is only looking after the machine and using it for the betterment of the patient.
The Management Conundrum
How will you apply the algorithms? And how ethical are you going to be in applying the algorithm? You will find that in India, there is no multi-speciality hospital with a thriving ophthalmology department, except for one or two in the whole country. Management specialists running the hospitals merely go by the returns and do not sanction funds. But if I start using these sophisticated machines, my overall practice changes. More number of patients get diagnosed and then they may go for another procedure. If they go for surgery, it becomes safer and the results get to be superior. So the whole system changes. That’s how we must look at it.
The cost of getting this kind of test depends on the centre and would be anywhere between Rs.2500 to Rs.5000. You must take it as insuring your eyes for Rs.2500 a year. Of course, apart from eyes, we have got many other organs in the body, and medical insurance—unlike in the US or Australia—does not cover the cost of investigations. But once you do that, your premium is going to shoot up and the number of premium paying capable patients or population is still low in India. A sobering thought is you need finance to do anything.
China is Way Ahead
Two decades ago, both India and China were considered poor countries. India has been having the SMILE technology for about 10 years and the total number of SMILE machines in India are about 35. I bought the first generation machine eight years ago and mine was the fourth in the country. I have bought the upgraded version, which is the second in the country. It looks good. But China has 550 machines.
That means the GDP is running the engine. Another aspect is that the oriental race has more minus power than anybody else. That’s the second point. Eight weeks ago, I was in Singapore for a user’s meet. A Chinese guy came up and made presentations and the number of surgeries they have made were mind boggling. What really puts the scale at an even keel is they charge two and a half times of what we charge our patients. So finally, whatever we want to do in technology, technique or delivery of anything to the patient, there has to be finances. And that can only come as our GDP keeps going up.
The eye is a fluid filled structure. There is a continuous manufacturing and circulation of fluid and that’s slowly going out through another pathway. The balance between the two keeps up a certain pressure which is normally between 12 to 18 mm of mercury. Anything higher is not good. Lower is not a problem but too low is not good at all. When it goes higher, there is a pressure effect. The optic nerve bulges. As the pressure keeps increasing, the nerve fibres keep dying out. Slowly the patient may lose vision on the sides, while the central vision is still good.
How does somebody get glaucoma? Most of it is genetically predisposed. If one person in the family has glaucoma, the chances of the siblings having glaucoma are very high and of the next generation are 50% lesser but they are still there. It can be easily detected, provided one makes a visit to the doctor.
When you lose fibres on the top, you lose vision at the bottom and vice-versa. The person cannot see the lower half, but can see up and look straight. When they go down the stairs, they’ll have difficulty; otherwise, they may not even know that they have a problem. The field test is the diagnostic tool and it is considered the gold standard.
Its prevalence is next only to cataract. This is the most common blinding disorder in the world. In the darker skinned races, it is more prevalent, particularly because our irises are thicker and have more pigments and we are more prone to glaucoma, than a lighter skinned person. The conventional computerised testing procedure is pretty much cumbersome, particularly because most of the patients have glaucoma in their 60s, 70s and 80s. The machine also gives giving false positive and false negative results. So it can be quite confusing and getting accurate results are sometimes difficult.
How do we diagnose glaucoma early with OCT? With OCT, you can actually count the number of cells and the number of nerve fibres and it gives you a graph and an algorithm that tells you if you have or don’t have glaucoma. OCT can catch glaucoma one to two years before the person comes up with a field defect. This is highly sensitive and highly specific. It is very tempting to use it on a large number of patients. But then, we would like to look at patients who have funnily shaped disks, aged above 45 and patients with a family history and then put them on this. Here again, a large number of patients would come out as negative, which is good, but he or she needs to get these tests repeatedly done. That’s again a burden on the pocket but there’s no excuse for that and they must do it.
ERG or Electro retinogram has pretty much been there for 30 to 40 years. The machines are very expensive and cumbersome to use. You have to put multiple electrodes and it will take 30 to 40 minutes. So the patient will really feel uncomfortable. But now, you can do the same electrophysiology with just two electrodes and it’s fantastic. It doesn’t give you just the raw output. It gives it to you on a number and a colour scale.
AI, the Next Stop
There are a lot of issues that come into play, and finally, all of it boils down to applicability of a particular test to a particular group of people and how to make it cost effective. There’s only a particular level to which the cost effectiveness can be done by the doctor. The paying capacity of the general population has to increase. When economy improves, health improves, wealth improves and everything improves.
So in summary, advanced technologies are available for early diagnosis of potentially blinding diseases. They have high sensitivity and specificity. They are totally safe and non-invasive. They are rapid tests and will take less than 10 to 15 minutes. There is no great discomfort. Now artificial intelligence is coming in. As I told you, the retina is the only place where you can look at the blood vessels. You can now see how blood is flowing. AI is now able to compute miniscule micron level changes on the retinal vasculature and predict if the person is going to develop renal disease, cardiac disease or neurological disease. Google is working on this.
Q: Will exclusive ophthalmologic diagnostic centres in public space, just like the scan centres available now, help in bringing down the diagnostic cost?
Dr: There are centers like that in Chennai itself but that does not make it any cheaper and does not reduce the cost to the patient eventually. What we all have to work towards is increasing the paying capacity of the general population.
Q: Can cataract be prevented?
Dr: Cataract is an aging process. It varies across races. For the Indian race, cataract occurrence between the age of 65 and 75 is the most common. It could come earlier or later. But the point is, you cannot prevent cataract. It can be dealt with.
Q: Does yoga help in preventing eye diseases like cataract and glaucoma?
Dr: Yoga will make you healthy and better health will reduce a lot of diseases. But, I don’t believe that yoga is going to reduce the chances of developing cataract or glaucoma.
Q: How safe is it to do eye testing in optical retail outlets? Why does the government permit this?
Dr: Yes, it is safe and you can’t get into any trouble because of that, because testing vision is just one part of testing the eye. If you come to the doctor, the vision will be tested, intraocular pressure will be tested and the optic nerve and all the structures of the eye will be looked at by the doctor. If something is not alright, then further tests will be done. So you’re able to stop a problem at the first level. But imagine a person has got early glaucoma. The optical outlet will not be able to diagnose it. They can only tell you if the vision is normal or not. So it would be much better to visit an ophthalmologist and get a proper eye test, particularly for anybody over 40 years of age.
Q: Are contact lenses safe? How often are they to be changed?
Dr: Contact lenses are safe if they are clean; unsafe, if dirty. The person who’s using it either has not been trained to maintain it or has become lackadaisical in the maintenance. That’s where it starts to go haywire. Usually, we prescribe monthly disposable lenses. To be 100% safe, you can use daily disposable lenses but it’s a little expensive and absolutely safe. But contact lens is only a temporary solution. If you are looking for permanent solutions, go for Lasik.
Q: How do computers, mobiles and other devices impact vision?
Dr: The common misconception is that we are getting rays from cell phones and laptops. There are no rays coming out from any of these products. All over the world, myopia is on the increase and which is corrected with minus power glasses. Why is that on the increase? One explanation that is given
is that evolution wise, we were hunters always looking at the distance and that brings in myopia. Today, we look closely at the text books, laptops and mobile phones. To counter this, a growing child needs at least one to two hours of natural sunlight exposure. We must encourage our kids to go out and play and get more exposure to sunlight.
The reason why a doctor normally advises not to use a cell phone is it is too small and because it is smaller, we bring it closer and that causes eye strain. It is better to work on a laptop or a desktop computer than working on the mobile. We have to learn to live with these products. All of us are going to use computers a lot and people in the software industry must follow the 20:20 rule. Every 20 minutes, get up and stop working. Look at the distance for 20 seconds. That’s what we want you to do.
Q: How do you promote patient education?
Dr: We have a whole bunch of YouTube and Instagram videos for patient education. That’s the easiest way to reach out to the population.
Q: In Pondicherry, there is an organization that can treat the eye problems through a simple two weeks session using ball and oil. Is it useful to take the session?
Dr: Twenty-five years ago, I’ve sent my people to get trained there for one whole month and we tried to replicate it here. But none of these exercises can reduce the glass power. Let’s be very clear. But these exercises really do wonders for non-specific discomforts. There’s no harm in doing that and it probably does some good. But if your aim is to reducing or getting rid of your glasses, it doesn’t work.
Q: How safer is Lasik? If safe, why do many ophthalmologists wear glasses?
Dr: I wear glasses and that’s for reading. Anybody over 40 needs to wear glasses for reading. Lasik is safe and it works as of now, with close to 99.8% success rate, for distant vision. Not for reading and that’s why most doctors continue to wear glasses. My daughter-in-law has Lasik done by me. My daughter has undergone Lasik and it is very safe as long as your cornea is fit to undergo the treatment. Lasik is about 30 years old. Now we have got something called SMILE, which has taken out all the small niggling issues in Lasik. There are different technologies available and depending on the technology that’s used, it can cost anywhere between 50K and 60K.
Olympic Gold Quest (OGQ) is a not-for-profit organisation co-founded by sports legends Mr Geet Sethi and Mr Prakash Padukone. The mission of OGQ is to help Indian athletes win the Olympic and Paralympic games. Mr Viswanathan Anand, Indian Chess Grandmaster & Former World Chess Champion; Mr Geet Sethi, World Champion, Billiards & Snooker; and Mr Viren Rasquinha, Former Captain, Indian Hockey Team & CEO, Olympic Gold Quest, discuss the challenges of players and their conditioning.
Viren: This is a question for both of you- Anand and Geet. What is the role of parents in your journey?
Anand: I learned how to play chess from my mother and I was quite fortunate. Typically, most chess players of that time learned from a family member or close friends. If you were lucky to have someone in your family who knew how to play chess, then it increases the odds that you might play chess. It was very serendipitous. My mother and her younger brothers played chess. So there was some background. I was six years old. One day, I saw my elder brother and sister playing. I wanted to join and of course, as the youngest, my mother said, “Okay, I’ll show you how to play.”
Then a few days later, they saw that I kept on coming back to the chess board. This might have been a bit of a surprise to them. I can see it myself. I teach my son something and you never know if he is going to forget it in a day or continue. My mom bought the first chess book for me. I would look at it but it was total mystery. Then they found the first chess club. My sister’s college happened to be right opposite the chess club. My mother took me to the chess club and I joined it. As I was very young, my mother was concerned because the general profile of a chess player was someone who’s much older and she wanted me to be safe.
A couple of people at the club said, “Okay, Don’t worry. We will look after him and make sure somebody plays against him.” That’s how it began. Maybe my parents thought at that stage, it was just one more hobby. I was playing other sports in other places but Chess was the thing that I was most attracted to. Every Monday evening, every Thursday evening and the whole of Sunday, I would go there and just play blitz all the time. Then the first few competitions started coming when I was seven or eight.
I went to the Philippines for a year but I was still only in fifth standard. Once again, in the Philippines, when we landed, my mother immediately found out where I could play chess. She would take me to every tournament, accompany me to the venue and make sure I got through. There was a Chess TV show during the day and they would give a puzzle at the end. But I would be at school during the show. My mother would write down everything and after I came back home from school and finished my homework, I would look at that puzzle. So my parents were very, very committed. My father was very supportive as well, though he didn’t know anything about chess.
By the time, I came back to India and was in ninth standard, it was becoming tricky, because I started to travel everywhere to compete. My parents could see that I was really keen on the game and pretty good at it. I was one of the top juniors in the country. I’d had a breakthrough year and was even one of the top players in the men’s game. They might have been nervous at that stage. But I’m grateful that it never occurred to them to try and warn me off from playing Chess. It’s not a nice feeling for children, if they don’t feel that their family is totally behind them. The most important thing is to hold your tongue. Even if you’re uncomfortable, just let it go.
I was very lucky with the timing of many things that happened to me. When I did my 10th standard exams, I became a national champion. A few months after my 12th standard, I became the World Junior Champion and then later grandmaster. When I finished my B.Com, I was already in the top 10 in the world. Of course, later on, my parents said “We always knew about you.” Honestly, I don’t think, it would have happened without the support from the family. My mother was the reason I got into the game. When a lot of people would tell me not to play Chess so fast, my father had the sense to tell me, “Play fast and you can’t be otherwise.” I kept doing that and it turned out to be one of my strengths.
Viren: Fantastic Anand. I remember you were called the Lightning Kid. By the way. I have a nine year old daughter. So one thing that stays with me is to bite my tongue and not to say anything.
Geet: Let me pick up from what Anand said. When I was in 10th standard in 1976, I won the first ever Junior National Billiards championship that was held and I had played exactly for two years. In 78, I won the juniors again, but I didn’t win the seniors. So finally I won in 81 in Chennai, defeating Michael Ferreira. The role of parents is absolutely there. My dad was a very wise man and he came from a lower middle class kind of a family. When a person like Anand at the age of six sees a chessboard and keeps coming back to it, I think parents get a sense that this something abnormal and can see when you are so deeply committed to a particular sport. I used to play every sport in school- volleyball, cricket, basketball, table tennis and badminton. I was a state level swimmer.
But when, at the age of 13, I started playing billiards, I just stopped playing every other sport. I was playing seven or eight hours a day and was living in the billiards room. I was not just passionate but kind of obsessed in the game. My parents recognised it and were a little lenient. My brother was supposed to be in the top 10 in the class, but for me, my dad said, “It’s okay if you try and get anything over 60%” So I used to stop playing it two months before my board exam and put my cue aside and just study. I would get just above 60. Really, it was a deal and I kept it up. So that was the support part of it. He just allowed me to flourish, though he would never come and watch me play.
Polishing dad’s shoes
But I think parent’s play a very, very important role, once a child wins a junior or a senior national championship at a very impressionable age. Looking back, I think my dad’s greatest contribution is what he did to me or how he behaved and interacted with me after I won a big national championship. The year was 1976. I was doing my 10th standard. I went to Jamshedpur to play the first ever junior nationals held and I came back as the winner with a massive silver trophy. Earlier, I had won cups in TT and they used to be so tiny.
Now carrying this huge trophy through a 48 hour train journey from Jamshedpur, I reached Ahmedabad and my dad was at the station with his Lambretta scooter. He hugged me and picked my bag. I took my cue and sat behind him on the scooter with the trophy in the middle, between him and me. He drove the scooter proudly and we reached home. My mom took aarthi for me and had made some lovely suji ka halwa and a great meal. It was about 11 in the morning. My dad was sitting quietly by the side. My mum finished with all her indulgence and I thought I should win more titles, so I would really be pampered. I ate my meal and my dad did the most amazing thing, as I see in retrospect.
He casually told me, “Beta. Can you polish my shoes?” In fact, we used to polish our shoes together- My brother and I used to sit down with dad and would polish our school shoes and dad would polish his shoes to go to his office the next day. It was the most natural thing and I said, “Sure dad. Which one – that brown or black?” He said, “The brown one,” and I started polishing his shoes. If I look back, every time when I came back with a big trophy, he would either ask me to polish his shoes or wash his scooter or clean the carburettor. He just kept me grounded with these very subtle acts. When you’re growing up, it is so easy to think, “Oh, I’m kind of God’s gift to billiards!” and get carried away.
Viren: Nine world titles. So, there must have been a lot of very clean shoes in your house (laughs!) What has been the most memorable moments for both of you in your long career?
Anand: For me, my world titles are definitely memorable, because each one literally is the payoff for years and years of effort. And the sad thing is, it gets over and five minutes later, you think, ‘Yes. That’s it.” If I had to select one, I would select my match with Boris Gelfand in 2012, simply because in that whole match, it felt like I was just surviving from day to day and then only in the tiebreaker, I was able to win. But there are moments I remember more fondly. There will be junior tournaments from school, of which, I remember some games, only because I beat somebody I really disliked. It’s a beautiful feeling and it lasts longer than the world title wins! (laughs)
The most pleasant experience is when something unexpected happens. So many times in my career, I’ve hit a wall where I might go a long time with mediocre results. You think you can’t get any worse and spend months trying to get out of the hole. Once you hit the bottom, then the only way is up and you will come out. So over time, I became more relaxed in these situations.
For example, I was going to play the World Chess Championship in 2017 in Riyadh. When I was going there, I had just come off with the last place in a tournament in London. It was totally irritating as there was no need to be in the last place. Every time I thought about it, I got angrier. Anyway, I went to Riyadh when I was not even supposed to go there. My original plan was to go on a holiday. But then somehow, somebody called me and reluctantly I went there thinking tenth place would be nice. After the three day tournament, I suddenly found myself as the winner. It is much better to have a good one after a bad patch. Finding the light at the end of the tunnel is beautiful and memorable.
Geet: I won my first world title in 1985. When you win the first world title, it always has a special place. The World Championship used to be held every two years at the time. In 87, I defended my title in Belfast. Then I went through a very bad patch between 88-89 and 92. For three years, I was playing at a very high level of performance and then my game dropped off a cliff. It took me three years to rediscover my game. I unlearnt my old technique, built a new technique and finally came back in 92, and won the World Professional championship. I defeated Mike Russell in the finals and in that, I made a world record break of 1276. That stands out to me.
Viren: As a sports person, very often, you will lose more than you win, especially in the initial days of the journey to become a champion. What’s your mindset when you go through a bad phase? How do you come out of it? Is there some go-to process that you follow?
Anand: Generally, it’s a process. It’s very difficult to force because you’re fighting with your brain and it’s got a mind of its own, so to speak. It’s similar to the stages of grief. First is to come to terms with what has happened- the sense of loss or whatever. That takes much time and then you take responsibility. This is very important. Because very often when things go wrong, it will seem to you that you could have done better. But then the question is, “Why does it go wrong anyway?” I have to work backwards and accept that. Then you come out of it and come to terms with the whole thing and then things work out. The last stage is very crucial. I have found that it almost always correlates for me with a huge drop in expectations, where I cease to care about the result.
Typically, after a very bad result, I disconnect from the game and want to go on a holiday. I do not even read about anything that is happening in the world. I’ve done this consistently. Before the world candidates’ tournament in 2014, I did not even look at Chess for one and a half months. The farther you get from the thing, it often allows you to reset and get back in. We train a lot to be on autopilot. But once in a while, we consciously have to push here and there and see what comes out. Then at some point, it will work and you’ll feel lighter and you start playing again. So you can’t expect to do the same things and get different results. You just have to keep experimenting.
Viren: In matches, when you’re down by a big margin, what’s your mindset?
Geet: Billiards and snooker are in that sense very brutal, because it’s a four hour game. Sometimes the finals used to be over eight hours. When you’re playing a final against a really good player, he could be making a break of 500 or 600, or 700. He’s occupying the table for almost 30 minutes. He’s playing beautifully and the crowd is appreciating it. The scoreboard is right in front of you. A flood of thoughts can come to your mind. So what I did very early on was to question me as to why I chose to play the game. I play the game because of some kick that I get while playing it. We will go to places just to watch excellent sport being played, whatever it may be. When I’m playing against one of the best players in the world, why can’t I just enjoy the game? And so that’s what I did. I just started getting involved in the act of my opponent’s play. You forget all the negative thoughts and you are just appreciating. I’m a great believer in positivity and positive thoughts.
The minute I start thinking negative, I am going to go low. I enjoy the opponent’s game and keep saying, “My chance will come and he’s damn good. I’m equally good.” So the bank balance of practice and the confidence that you have attained over the last 5 or 6 or 7 years of performing to that level, gives you a high subconscious confidence.
On the expectations of the audience, I’ll share a small story. In my first Junior State championship, I was playing the finals with a young kid, who was one year younger than me and I was trailing by 300 odd points. It was a club. My mom walked in and I could I see her. She was damn excited. She talked to a few people about the score and I could see her sad face. I don’t know what happened to me. I just got up, walked around the table, went to mom and I said, “Mom. Please get out of the billiard room.” That was the first and last time she ever entered a billiard room. The point is, as a kid of 15 or 16, I didn’t want the additional burden of expectations. You don’t play to get a smile on the face of the audience or your supporters or your family members. You play for the joy of playing and I think that’s a very important point.
Viren: I remember when I was in ninth or tenth standard, the hardest thing to do was to get a smile on my mom’s face when she saw my marks in my chemistry paper. My mom was a doctor and dad an engineer. My elder brothers were engineers. But I couldn’t understand any equation in chemistry. They thought afterwards that I better become a good hockey player (laughs!). Tell us about your iconic battles.
Anand: For me, probably it would be battles with Kramnik. I remember seeing him for the first time in 1989. He was 14 years old and much taller than me. He was a huge guy. He came in a T shirt and shorts. From time to time, he would even go out for a smoke during the match. In 89, it was still allowed. He made an impact visually itself and he seemed nice and friendly. We drew our game and spoke a little bit.
Then three years later, there was suddenly word about a Russian kid whom I’d forgotten. Once again, we played in the same tournament. I was playing in the main tournament and he was playing in the Open Tournament, which he won. He’s one of the first players who never became an international master. He went straight from the previous title all the way to Grandmaster. Gary Kasparov in an interview said, “This boy is absolutely the future of chess. I have never seen anyone as strong as him.” When I wondered who he was and looked at the name, ‘Kramnik,’ I couldn’t connect the dots. But once I saw him, I could recognise him.
Our rivalry started in 92. Very soon we were second and third. Our rating was always just a little bit apart, till our World Championship match in 2008. Even after that, I only thought of him as a rival. He retired in 2019. It didn’t last long and he’s back playing online. With him is my longest rivalry. I have then had rivalries in stretches with Karpov, my first big rival. For three, four years I was battling him everywhere. Then, it was Kasparov. That was more of a triangle with Karpov, Kasparov and Kramnik for a couple of years. Then Topalov suddenly became one of the best. There were these on-off rivalries. At the end of that, there was Magnus Carlsen and it was much shorter. The birthdate of my rivals span from 1951 to 1990. Karpov was born in 1951 and Magnus is 40 years younger than him.
Viren: That’s a testament to your longevity in the game.
Anand: I also feel that Kramnik is one of my best friends. Even during the rivalry, I always had a soft corner for him. He also reached out and helped me in a couple of very difficult situations. He gave a lots of good career advice.
Geet: I played players from different generations. For my first world title, I beat a guy called Bob Marshall, an Australian who was 74 years old. He was exactly three times my age of 24. He came out of retirement to stop Michael Ferreira from beating his world record of 4 titles. He had a steel hip and steel in both his knees. We both played the finals together in the world championship that I won. And then of course, Michael Ferreira who was double my age in that same tournament. I had a fair bit of rivalry with Michael through the 80s. Then in the 90s, it started with Mike Russell and what a great player he was- a British player, fabulous player, absolute master with a great delicate touch and stupendous concentration. He had a street fighter mindset. In the 90s, I kept beating him but then in 2000s, I just could not beat him in any final except once, I think in 2003 in New Zealand. That was a great rivalry
Viren: What is the role of luck in sports?
Geet: My personal take on luck in sports is that in the game that you’re playing, luck will even out. In cricket, you give a lollipop catch to somebody and the guy misses it and you’ll go on to score 100. That’s great luck. But that will even out because somewhere down the line, you will give a very difficult catch and a guy will run 25 yards and then dive and catch it. But for me, more important is the luck that comes in life, in how you have progressed and in the people that have come across at just the right time, at the right place. I think the universe arranges itself in such intricate patterns to see that something good happens to you. It happens to all of us. We should remember that. I’ll give you a story about how a very significant luck happened to me and because of which, I got so much competence and my career really took off.
The year was 1984. I wanted to go to England to play in the professional circuit in England. I was working for a company called Tomco and was going through a little bad patch in my game. My President walked in and seeing me with a long face asked me what the problem was. I said I’m not playing well and want to go to England to play and get international exposure. He just picked up the phone and called the travel desk and arranged return tickets to London, for me and two more of my sporting colleagues.
1800 rupees was my salary and 8000 rupees was the ticket cost. We had the tickets but still needed money to stay in England. We were three of us – youngsters wanting to go to England. We collected about 700 pounds and said that once we ran out of that, we would return to India.
We went to England and lost in the first tournament. We took a coach and went to the next tournament next week. Every weekend, there was a tournament and by the fourth weekend, we were down to our last 100 pounds. We thought it was time to go. So with our bag and cue, we were walking across the car park, going towards the town center, to take a coach to Heathrow airport.
As we were walking across the car park, just about 20 yards ahead of us, there was an Indian looking guy who was just closing the boot of his car and about to drive away. He turned around and called us. We walked towards him. He said, “I saw you guys. You are playing very well.” I said I’m a national champion and introduced my friends as the national snooker champion and the national snooker runner. He introduced himself as Praveen Patel and asked us where we were going. We explained we were going to Heathrow to take a flight back to India as we had run out of money. In a split second, he said, “That’s okay,” and opened the boot of his car, put all our bags in, shut it down and asked us to get into the car.
As he started driving, he started chatting. “I’ve come from Kenya. I was a refugee here,” he said. We were telling our story. We thought he was taking us to Heathrow but he went past Heathrow into Luton and parked outside his house. His wife opened the door. He told her in Gujarati, “These are my friends. They will stay with us.” She said, “Oh, Brothers. Come, come.” She got us meals.
It was a two and a half bedroom house. Praveen Patel had his mother and brother staying with him. He was recently married and he had just one bedroom to stay in. His living room was 10 by 10 with a small little dining room, which was eight by seven. It was a very small and modest house. Patel told us, “You have come from India. You got to practice. You have to play and win. I will help you.” We slept in that 10 by 10 drawing Room.
Next morning, he took us to the local club and paid the charges for our table. He shelled out 12 pounds that day. Over the following days also, we practiced. Then there was another weekend tournament, a big one. Till then, we were eating burgers and sandwiches and fish and chips. Suddenly we were getting lovely keema gravy and roti at home. Our laundry was being done. We were in so much comfort and could practice our game. In one of the tournaments, I won and got 3000 pounds as prize money. That was loads of money.
Now just look at this guy. If we were walking out three seconds later, he would have shut his car door and would have been off to Luton. That three seconds gave us chance to be with him. It gave us confidence to play on to win tournaments. In 1985, I won the World Billiards championship and Om B Agarwal won the World Snooker championship in Dublin. That I think is luck.
I do believe that all of us get this break. We need to remember it and articulate it. We need to keep repeating it. We keep saying, “Oh, in that tournament, my knee broke. I was so unlucky. I missed my flight,” and so on. We look at all the bad luck that happens and we never remember the great luck that happened. Just to end the story, Praveen Patel at that point was an unemployed car mechanic and this is what he did for us.
Viren: What a wonderful story! I just want to say a few words about OGQ. It is a not-for-profit organization. We look after the training and preparation of some of India’s best athletes from the best young talent and prepare them for the Olympics and Paralympics. We currently look after the training of almost 365 athletes. We focus on individual Olympic sports and also coach for badminton, boxing, shooting, archery and wrestling. We support athletes by trying to ensure that they have the best coaches-Indian or foreign, the best training facilities, be it in India or abroad and we ensure they have the best equipment in sports. We’ve also put together a team of world class doctors, physios, nutritionists, mental trainers and everyone in the background to help these athletes. I’m really proud to say that in the last three Olympics: London 2012, Rio 2016 and Tokyo 2020, India won a total of 15 medals and the training of nine of the 15 medal winners was supported by OGQ.
Three and a half years back, we started supporting Paralympic athletes -athletes with physical disabilities. We currently support 84 para athletes, several of them on wheelchairs, some with amputated upper limb and some with amputated lower limbs. We do not support them because of their disability. We support them because of their abilities. These are exceptionally talented young athletes. It’s been such a beautiful and humbling experience to support the Para athletes at the Tokyo Paralympics. India won 19 medals. The training of 10 of those 19 medal winners was supported by OGQ. In 2022, there was the Birmingham Commonwealth Games. Athletes supported by OGQ participated and won 17 medals including 12 gold medals. It takes just six grams of gold to lift the worth of a nation. That’s the weight of pure gold in an Olympic gold medal. And that’s what we strive for at OGQ. This organization is founded by Geet Sethi and another legend Prakash Padukone.
Geet: At OGQ, we provide dignity to the athlete. Imagine runners going to a championship without shoes. Or if they have the shoes, they don’t have the necessary clothing. Imagine shooters going to a very big tournament without preparing because of the lack of pellets. We have brought into focus the fact that the athlete is the final stakeholder in the Indian sporting scene- not the sponsors, not the parents and not the political system. I believe that the political will has changed in such a lovely and positive manner and we’re living in great times for Indian sport. As we move ahead, I’m genuinely confident that in the next 10 to 15 years, we will be in the top five sporting nations in the world.
Viren: You have always mentioned about the pride and the power of sports as a tool towards nation building.
Geet: Yes. When an athlete stands at the Olympic podium as a gold medal winner, the flag of that nation goes up and the national anthem of the country is played out and it instils a very powerful emotion. That emotion is reserved not only for that athlete who has won it, but it also rubs off on all of us. We must strive to increase the frequency of that emotion. The sporting identities of nations are formed at the Olympic platform.
Anand: Like Geet said, I have learned to look back on my journey with gratitude. I had a very similar experience when I met an elderly Spanish couple. They practically became my second parents and I moved to Spain because of them. I had a German friend I met in India and a Dutch friend. I’ve stayed in their houses for months. Having said that, in my career, I have made a lot of mistakes. There were a lot of people helping me, but a lot of things I had to do on my own.
One thing that I realized was I’m not very good at all in certain things. A certain number of mistakes around that happen. To some degree, they shape your character. I’m not necessarily a good organizer. I do my best when I’m allowed to be thinking of chess all the time and not being distracted. From that perspective, imagine that there was an organization like OGQ that can support you in all sorts of practical ways. It feels like calling a friend and there’s no embarrassment anymore asking for help.
Viren: What advice would you give to young athletes or individuals aspiring to become champions in their chosen fields?
Geet: Whatever field you are in, you must enjoy that. Go and love that and keep improving in that field.
Viren: How do you maintain a balance between personal life and demands of being a champion in your life?
Geet: When I was in the thick of competition, there was no balance. You are so passionate and obsessed with the sports and the people who love you will understand that. Your parents, later on your partner and then finally your children will understand you. If there is balance, there is no excellence. In sports, excellence is necessarily a function of being unbalanced.
Viren: How do you stay motivated and continue to strive for excellence, even after achieving remarkable success in your career?
Anand: You need new goals. All goals, after a while, will bore you. It is very nice that we have the urge to find new ways of doing things and keep challenging ourselves. It’s nice to experiment. The changes are coming constantly and at the same time, it’s nice because we have new material all the time. There’s something new to learn. That’s the motivation. And besides, over a lifetime of playing chess, you have your ego and you want to go there and play a good game.