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Nuclear accident at Three Mile Island
March 28, 1979
Gas Leak in Bhopal
Dec 3, 1984
Space Shuttle Challenger disaster
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Chernobyl nuclear disaster
April 25, 1986
Exxon Valdez Oil Spill off Alaska
March 24, 1989
Grounding of cruise ship Star Princess in Alaska
June 22, 1995
Train wreck in Michigan
November 15, 2001

IT may sound strange but the missing link to all these disasters is sleep—or the lack of it. Most of these accidents occurred late at night, the men and women responsible for them were invariably overworked and sleep deprived.

If the list looks small, the reason is that sleep research dates back to a mere 30 years. And if the magnitude of the disasters leaves anything to be desired, add to it the thousands of fatalities that occur on roads, in hospitals and factories across the world because the driver or the doctor or the mechanic could not keep his or her eyes open any longer.

A 2005 poll in the US attributed 10,000 car accidents to sleep deprivation alone. And a September 2000 study done in Australia and New Zealand found that people who drove a car after being awake for around 19 hours, performed worse than people whose alcohol level in blood was 0.5 per cent.

‘‘It takes exactly 10 seconds for a sleep deprived person to fall deeply asleep. And in certain situations, if that sleep lasts even 10 seconds, it can do serious damage,’’ says Dr Sanjay Manchanda, who has studied the subject at St George’s Hospital in Sydney, Australia, and now heads the Sleep Clinic of Sir Ganga Ram Hospital in New Delhi.

It is important to underscore the fact that after the teen years, everyone needs eight hours of quality sleep everyday, say experts.

In effect, it means 33 per cent of life spent in sleep but with anything less, the result is hypertension, irritability, short-time memory loss, obesity, poor control of diabetes poor performance at work, strained relationships and an eventual heart attack. In short term, it leads to poor judgment, poor reaction and poor response to crises.

But perversely, today, at least 33 per cent of the population worldwide suffers from sleep deprivation—in the US the figure is close to 60 per cent—with disagreeable results.

Dr Ashok Mahashur, Head of the Department, Pulmonary Section of Mumbai’s Hinduja Hospital, who is also in charge of the hospital’s Sleep Clinic, recounts the story of a doctor who fell asleep and fell from his two-wheeler while waiting at a traffic signal. ‘‘Examination revealed that he was suffering from Obstructive Sleep Apnea, a sleep disorder which can even cause strokes,’’ he said.

The doctor himself had no clue about it—a situation that most alarms the handful of sleep specialists in the country.

The first Sleep Clinic in the country was opened in 1991 at New Delhi’s Safdarjung Hospital by Dr Jagdish C Suri. But although the number of sleep clinics has grown since— around a 100 across the country—there is little public sensitisation. In India, over 90 per cent of people with sleep disorders go undiagnosed. Worse, ‘‘only 40 per cent of doctors are aware of sleep disorders today,’’ says Dr Sanjay Sobti, Senior Consultant of Sleep Medicine at Indraprastha Apollo Hospitals, New Delhi. The Indian Sleep Disorder Association has around 200 members, says Suri, the founder and president of the association.

This is also the reason why the country has so few specialists in what is a highly developed field abroad. ‘‘Even today, no Indian medical school offers a course in sleep study,’’ says Dr Manchanda, who started out as a pulmonary specialist, and moved to sleep medicine due to his interest in the ‘‘33 per cent of the unknown’’.

Part of the reason is that sleep, even abroad, was considered a natural process for long. And while somnambulism and insomnia made an appearance in literature from Shakespeare to Keats, the scientific nature of sleep was little understood till in 1875, Richard Caton, a surgeon from Liverpool, discovered electrical activity in brains of animals. In 1913, Henri Pieron published Le problemme physiologique du Sommeil. In 1923, German psychiatrist Hans Berger developed electroencephalography. And in 1950s, came the next milestone with US physiologist Nathaniel Kleitman’s work on Circadian rhythms—the biological clock. The clinical aspect of sleep study developed only in 1970s and it was in 1996 that the American Medical Association recognised sleep medicine as a speciality.

Today, over 80 types of sleep disorders are recognised. But broadly, they can be classified into five categories. Of these, insomnia, the inability to go to sleep or sustaining it, and Obstructive Sleep Apnea are perhaps the most prevalent—prompting sleep clinics in India, clustered mostly in New Delhi and Mumbai, to concentrate on them.

Apnea, derived from the Greek word aponia, meaning absence of respiration, is the unnatural stoppage of breathing during sleep. The stoppage—due to obstruction caused by obesity and facial structure—can continue for anything between 5 seconds and three minutes and can lead to heart attacks.

‘‘It is an FDA guideline that every person who snores must undergo a sleep study,’’ says Dr Sobti, ‘‘for one of the warning signals of apnea is snoring, which typically happens when breathing is obstructed.’’

But the high prevalence of apnea is also one of the reasons why sleep, a multi-disciplinary study, is becoming the provenance of pulmonary experts in India. It is also why other equally alarming problems, like narcolepsy and parasomnias, are relatively unknown and under-diagnosed.

The word ‘‘narcolepsy’’ was coined in 1880 by French physician Jean Baptiste Édouard Gélineau from the Greek word narke meaning stupor and lepsis meaning an attack or seizure. Narcrolepsy is a spontaneous attack of sleep at daytime. It is characterised by excessive fatigue and for that very reason, is considered a fallout of stress. Even in countries well up in sleep medicine, it can remain undiagnosed for years. The record, according to the Stanford School of Medicine— which opened the first clinical centre for sleep—is 14 years. But narcolepsy is a nervous disorder, which is genetic in nature. The reason for the daytime sleepiness is that the quality of sleep at night is poor.

The sleep cycle consists of two parts, explains Dr Manchanda, the REM or Rapid Eye Movement sleep and the NREM, or the Non-Rapid Eye Movement sleep. The REM sleep is characterised by the movements of the eyeball, which is perceptible even over closed eyelids. The movements indicate the dreams the sleeper is having and for this reason, the REM sleep is also called the ‘‘dreaming sleep’’. The NREM sleep in contrast, is the deep sleep. It is divided into four parts —the parts three and four of which are called the ‘‘Delta Sleep’’ and are the most rejuvenating. In course of a night, the sleeper begins with NREM sleep then moves on to to REM sleep and back again.

‘‘But people with narcolepsy move on to REM sleep straight away and stay there,’’ he says. ‘‘This disturbed pattern ensures that despite a whole night’s sleep, they are not as rested and refreshed as ordinary people.’’

But daytime somnolence also marks apnea, points out Dr Manchanda, which is another reason why narcolepsy is difficult to pin down.

So are there other symptoms that are singular to narcolepsy?

There is cataplexy, a sudden muscle seizure that paralyses the patient for a few seconds in response to a strong emotion. There’s sleep paralysis, in which the patient cannot move for a few seconds upon falling asleep and waking up; and there is hypnogogic hallucinations— dream-like auditory or visual hallucinations, experienced while dozing or falling asleep.

The other neglected sphere in India is parasomnias, or unnatural activity during sleep, which includes a variety of disorders—Restless Legs Syndrome, night terrors, sleep walking, sleep sex and violence, which involves acting out a dream. This last, a REM sleep disorder, can result in injuries to a bedfellow.

Of these, night terrors have a special significance for children. These are effects of dreams that occur between the age of five to 12 years. Dreams can occur in the first two parts of NREM sleep too, says Dr Sobti. These are almost always unpleasant and always forgotten in contrast to the dreams and even nightmares of REM sleep. What stays is a feeling of fear, depression and listlessness.

‘‘Sadly, this is one part of paediatrics that is made little use of in India,’’ says Dr Suri, Head of Sleep Research at the Safdarjung Hospital. ‘‘The genesis of many adult problems can be traced to this.’’

The other most prevalent area of sleep disorder is what has come to be known as ‘‘shift work sleep disorder’’, says chest specialist Dr Sanjeev Mehta of Mumbai’s Lilavati Hospital, which is of particular importance in the BPO-land that India has become. In this, due to constant disruption of sleep schedule, the Circadian cycle of the body gets completely upset. The result can be anything from constant fatigue to hypertension and heart attack.

So if the average physician is unaware of these problems, how are these to be diagnosed and treated?

The lack of awareness among physicians about sleep study is not just an academic grouse. The most detrimental fallout of this is wrong diagnosis and wrong medication. The most common problem is a blanket prescription of sedatives.

The good news is that all the sleep disorders can be treated with very positive results.

But the only way to conclusively pin down the sleep problems is a visit to a sleep laboratory, where one may have to spend a night or two.

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