Powering down: Inside India’s sleep crisis

Even then, the sleep they were studying wasn’t sleep as we know it. From about the 5th century all the way to the dawn of the industrial age in the 1700s, it was common not to sleep through the night. Segmented or biphasic sleep saw people sleep in two shifts, the first from about 9 pm to midnight and then from about 2 am to dawn, with an hour or two of wakefulness in between. In that interval, they did chores, prayed, had sex.

“Biphasic sleep was not unique to Western households. It occurred well beyond the bounds of Europe and North America in other cultures and continents, including the Middle East, Africa, South Asia, Southeast Asia, Australia, and Latin America,” historian Roger Ekirch noted in his paper, Segmented Sleep in Preindustrial Societies, published in March 2016 in the journal Sleep.

There are references to it in crime reports from the 1600s. In his research, Ekirch cites a 1992 sleep experiment by Thomas Wehr, a sleep scientist with the US National Institute of Mental Health, that suggests biphasic sleep could be linked to an absence of artificial light. Wehr observed this habit form in 15 male participants who were exposed to only 10 hours of daylight a day. Measurements of melatonin secretion showed that their circadian rhythms had been altered within the four weeks of the experiment. In 2017, a study published in the American Journal of Human Biology revealed that segmented sleep is still prevalent in agricultural, non-electric Malagasy communities in Madagascar.

What this underlines more than anything, researchers say, is that there has never been a universal sleep pattern for humans. Even today, some people cannot sleep more than five hours at a stretch, but must nap during the day. Others sleep eight to nine hours and need no nap.

So what determines how and when we sleep? Since the 18th century, it has been overwhelmingly the industrial revolution and factors linked to it, from the emergence of work shifts to the prevalence of artificial lighting.

As industrialisation spread and economies began to boom, hyper-capitalist societies demanded something new of its citizens: spending. Now, it was leisure hours that stretched and began to eat into sleep times.

Screens have, of course, intensified the war on sleep. As have rising stress levels, poor diets, pollution (particularly air and light). But what’s really kicked the battle into high gear is the commodification of attention. Multi-billion-dollar multinationals from Netflix to Twitter to Epic Games — and these are just the giants representative of their fields — depend for their revenue models on keeping the user hooked. Netflix CEO Reed Hastings famously said his competition isn’t Amazon or HBO, but sleep.

The result: A binge-watching, binge-playing, doomscrolling population where the lines between consumption and over-consumption have blurred, even in the very young.

A study published in the Indian Journal of Physiology and Pharmacology in 2019 surveyed 1,457 students aged 9 to 17 and found that 8.6% were taking over 30 minutes to fall asleep (instead of the average of 20 minutes for that age group). The study was conducted by Col (Dr) Karuna Datta, a professor with the department of sports medicine at the Armed Forces Medical College in Pune.

The young people knew they weren’t sleeping early enough or for long enough either. Asked what was keeping them from doing so, the two top reasons cited were use of electronic gadgets (23.7%) and lack of parental control over sleep schedules as they aged (20.8% of boys and 13.7% of girls). “Some students showed erratic sleep-wake schedules such as going to bed at 3 am and waking up at 1 pm,” says Col (Dr) Datta.

Pandemic boost

One of the things that happened when the world came to a veritable standstill in the first year of the pandemic was that sleep times rebounded. People had less to do, and were simply sleeping more.

“During the pandemic, people started to realise that sleep is the third pillar of health after diet and exercise,”,” says Dr Seema Khosla, a pulmonologist, sleep medicine specialist, medical director of the North Dakota Center for Sleep, and spokesperson for the American Academy for Sleep Medicine.

But the pandemic affected people differently, Dr Khosla adds. Not everyone who was asleep was sleeping soundly. “A colleague who took care of Covid patients in the ICU shared with me how they were petrified to sleep at home because they were scared they would stop breathing and die alone.”

“In India, we were sleeping an average of six to eight hours a day before 2020, but in the first lockdown we added at least 30 to 40 minutes to our daily sleep duration,” says Dr Bhatia at Neurology and Sleep Centre. “This then dropped to about five to seven hours daily as pandemic restrictions were lifted and we tried to go back to our old routines but with additional problems such as fragmented sleep and anxiety in some cases.”

“I like to think that the pandemic was a wake-up call,” says Dr HN Mallick, president of the Indian Society for Sleep Research (ISSR). “It helped some of us realise how badly we have been sleeping all this while,” adds Dr Khosla.

Magic marker

How much does sleep matter? The view on this has changed dramatically in India since the early 1990s.

“Today there are more than 80 different types of sleep disorders that we know of, but before the ’90s so little was known about sleep that deprivation was linked only to non-life-threatening psychological conditions,” says Bindu Kutty, professor of neurophysiology and head of the Centre for Consciousness Studies at India’s National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru.

From the 1990s on, as India transitioned from a country plagued by infectious diseases to one plagued by lifestyle diseases, research began to lay out how conditions such as diabetes, heart disease, obesity and hypertension were all reflected in changing sleeping habits and patterns.

Now, sleep is seen as “the index of health,” says Bindu Kutty. “Poor sleep can signal depression, gastrointestinal disorders, musculoskeletal disorders. Inadequate restful sleep also causes decreased production of infection-fighting white blood cells, cytokines that help suppress inflammation and melatonin that alleviates stress and promotes sleep.” It is a core indication, of course, of mental wellness too. “During the pandemic, it was our best shot at decoding how we were really feeling,” Bindu Kutty says.

Brain drain

Globally, sleep research is now studying the intersection of neurodegenerative disorders and sleep patterns. A study by researchers at UC Berkeley, published in the journal Current Biology in September 2020, suggests, for instance, that there might be a link between fragmented sleep and the build-up of toxic plaque in the brain that occurs during the onset of Alzheimer’s disease.

Could a habit of deep, restorative sleep impact the onset of the disease? Why would there be such a link? These are questions researchers are trying to answer.

The body, meanwhile, is turning out to be a storehouse of clues on the secrets of sleep too. “We are at an exciting point where researchers are looking for biomarkers that could potentially tell us, through saliva or a blood test, for example, whether someone has sleep apnea. Research is no longer single-minded; we are diving into different facets of sleep,” says Dr Khosla of the North Dakota Center.

How are you sleeping?

In India, because of the lack of adequate data, it has been difficult to track how average sleep times have changed over the years. The lack of studies and surveys, doctors say, proves that we aren’t as perturbed by the changing sleep patterns as we should be.

Until 2000, sleep medicine wasn’t even part of the undergraduate medical curriculum, Bindu Kutty of NIMHANS points out. “All through the 1990s sleep was neglected in developing countries and so there weren’t enough sleep experts for people to turn to either.”

Even now, sleep physiology and sleep disorders make up a minuscule part of the syllabi. The Indian Society for Sleep Research (ISSR) has conducted courses and certification examinations for sleep technicians and accreditation for sleep laboratories since 2015. NIMHANS and AIIMS have both been conducting week-long sleep medicine training programmes since 2012.

“We have hundreds of sleep labs in India but research is limited and scattered because the health ministry hasn’t added sleep medicine research to its agenda,” says Dr Mallick of the ISSR. “The Indian Council of Medical Research (ICMR) hasn’t given sleep medicine its due importance either.”

ICMR admits there is a deep need for more sleep research in the country. “We have funded eight studies on obstructive sleep apnea in medical colleges so far. But while we have been researching diseases such as tuberculosis, leprosy, malaria and HIV and focussed on outbreaks like Covid-19, Nipah and Zika in the public health sector, sleep research has been assigned to medical colleges and the best we can do is keep funding them to investigate various factors,” says Dr Rajni Kant, head of research management, policy and planning at ICMR.

Meanwhile, people aren’t paying enough attention to their own sleep patterns. “People either do not know why they are always sleepy, or they know too much and develop orthosomnia — the obsession to achieve perfect sleep — because of all the sleep tracking devices available to them. Either way, it’s not good news,” says Dr Khosla.

A first step to addressing this is to introduce sleep awareness programmes in schools, says Col (Dr) Datta. Learning to decode sleep at a young age is an important life skill, she adds.

For their part, doctors have added sleep to their introductory list of questions. Alongside queries such as “Do you exercise” and “Have you lost an unusual amount of weight recently?” they have begun to ask, “How have you been sleeping?”

An ancient remedy?

Now for a really interesting twist: There is a technique now being used to make up for diminished sleep times that traces its roots to ancient Indian systems of medicine.

In an interview with The Wall Street Journal in February, Google CEO Sundar Pichai said he liked to unwind with the help of non-sleep deep rest or NSDR, a term coined by Stanford neuroscience professor Andrew Huberman. “While I find it difficult to meditate, I can go to YouTube, find an NSDR video… so I do that occasionally,” Pichai said.

NSDR is a state similar to yoga nidra (generally explained as guided awake-sleep). Recent studies by Indian sleep researchers have been focusing on understanding the role of yoga nidra and NSDR in improving sleep. Col (Dr) Datta has been using yoga nidra to improve sleep duration and quality in high-performance athletes.

“We were looking to use non-pharmacological approaches to target sleep disorders and formulated a therapeutic model of yoga nidra,” she says.

Similarly, Bindu Kutty has been studying brain activity in yoga practitioners since 2000 to try and assess impact on sleep. It is important to note that doctors on both sides say the practice must begin with the guidance of an expert.

Does it have to be this complicated? “As a species we haven’t really forgotten the simple act of sleeping well, but have over the years packed too much into our lives and set unrealistic expectations around sleep onset,” says Dr Khosla of the North Dakota Center. We must simply declutter the mind, she suggests.

Dr Bhatia of Neurology and Sleep Centre adds that it is also vital to close the “insomnia conversation gap”. “Everyone agrees on the importance of sleep,” she says, “but doctors and patients need to acknowledge the elephant in the room and discuss even the small changes in sleep patterns. No sleep information is irrelevant.”