Blissful Life

When you apply skepticism and care in equal amounts, you get bliss.

Year: 2021

  • Is Science The Only Way of Knowing?

     This is continuation of a debate from YouTube.

    The statement that “Science is the only way of knowing” is correct. But it is also arrogant.

    The definition of knowledge that we are working with is “justified belief of independent rational observers”. What I argue in the video is that independent rational observers can come to different justified beliefs when it comes to social science where the observations are made about human behavior. I gave the examples of economics, politics. That when two independent rational observers look at the “market” one comes up with socialism and the other with capitalism. That there is no way for science to figure out which of them is the “truth”. And that this lack of convergence on one justified belief is what makes the argument “science is the only way of knowing” break down.

    But using “logic” (which can also be called scientific method) is the only way for humans to know anything, and that’s right. Those who defy the commonly accepted “logic”s are considered psychotic by human beings.

    Where is the arrogance? The arrogance is in claiming that “science is the only way of knowing” when it is clear that there are very severe limitations for science when it comes to the field of social science. A society cannot be subjected to controlled experiments. What science requires to arrive at the truth, to “know” how a human society will function is a set of observations from which one can draw conclusions. It is impossible for human beings to perform this set of observations in the way that’s required to correctly draw such conclusions and “know” the human society. And that is the fundamental limitation of science.

    To claim that theoretically it is possible to isolate all the variables and test a hypothesis about human beings – that’s useless at best, and politically inappropriate at the worst.

    In the video I try to keep physics, chemistry, etc from the uncertainty about truth that I introduce. But in response to the video Pirate Bady brought up the argument that ‘single’ truth does not exist in even physics. That quantum mechanics, for example, has infinite truths with different probabilities.

    I don’t know quantum physics. I have no perfect idea how exactly Schrödinger’s cat is a paradox. Which is why I omitted talking about this in the video.

    But if physics is also observer dependent, then that’s another argument which weakens the idea that “science is the only way of knowing”. That multiple truths can exist and we won’t be able to come to a single truth translates to the idea that – “we cannot know certain things”. 

    From that it can be argued that if there is a way to know it is only through science and consequently, “science is the only way of knowing”. And that’s a big if clause.

    If there is a way to know, science is the only way

    I can stand by that statement.

    Because it admits that there are times where we cannot “know”. Be it quantum physics, be it politics or public policy. That’s a humble statement. That’s a statement which accepts the limits of science. That is a statement which gives space for “other” ways of “knowing”.

    The only argument against giving space to these “other” ways is that it can lead to irrational thinking in human beings. And I think that’s the argument Dr Viswanathan makes too. And I think that’s also the reason why science has not been able to win people over despite so many accomplishments it has had. That science fails to acknowledge what is fundamentally human. That science, in its ivory tower, arrogantly believes that all that the world needs is science. 

    If only more rational thinkers admitted that there are times when humans can’t know and that science has no role in such times, we can then start negotiating with irrational people and push them to use science in all the places that matters.

    Yes, that means that we will have to tell them that science cannot tell them whether there exists a God or not. But that’s okay. By accepting a humble position like that, you make science more welcoming to all humans. It is by being arrogant that you drive them away.

  • History Taking Through Heart

    I was trying out the Daily Rounds app on Android and came across a case description “Unilateral limb swelling in a 51 year old lady. No comorbidities. KFT normal. How to proceed to diagnosis?”

    This reminded me about how clueless I was about history taking during medical school. I think if I’ve learnt anything well by now, it is on how to take a detailed history. And looking at this question made me realize how much that helps me in coming to diagnoses. So here are some super simple tips to take detailed history while building a personal connection – which doesn’t require any knowledge of pathology or medicine.

    Start with the person

    You might have learnt that asking for name is the way to build rapport. But that’s a lie. Asking for name is so you can write it in your notes. If you want to build rapport, talk to the person in front of you (and not the patient). I’ve found that the question “have you had breakfast?” in their language (adjusted for the time of the day) is a super simple way to build rapport. And the reason is that this is what regular people usually ask each other casually when they are on the road.

    This lets the patient relax and breathe free. With just one sentence you’re telling them that you’re a human like them and you respect them like another human. That their sickness is secondary to their human existence.

    Move to the patient

    Now you let them talk. Unless they’re experienced, they will not have arranged in their mind what to tell you. For the first few minutes, let the patient speak without interruption. Let them figure out what their problem is while they’re talking to you. Use only head nods, and “hmm” to communicate that you’re listening. Make sure you’re looking at the patient and don’t give off an impression that you’re not listening.
    If the patient stops after describing just one symptom, just give it back to them as a question. 
    “I have headache” Long pause.
    “Headache?” with a puzzled, but caring face.
    Awkward long pause.
    “Yes. The right side of my head feels like it is exploding, since yesterday”
    “Hmm. Tell me.”
    “That’s it. I’m unable to get up from bed.”
    Pause.
    “And everything becomes dim and dark to see”
    …
    Once you let the patient figure out that you’re there to listen, they’ll tell you everything you need to know without asking.

    Get the timeline right

    Once you know the presenting complaints, it’s time to arrange them in the right order with dates. Ask specifically about when they were completely alright. Get as specific a date as possible about when things started. (The longer people have been having symptoms, the less specific you can get. But still.) Retrace the course of their illness from day 1 of symptom. Find out the order of symptoms. Find out the progression of illness. Find out what they’ve been doing (I betcha they’ve gone to another doctor already or tried something). Find out why they decided to come to you. (That needs a point of its own)

    Find out why they came to you

    There’s a reason the patient has come to you. This is not the same as the chief complaints. Some are scared and are coming for reassurance. Some are tired and want relief. Some have been referred by someone else for a specific reason. Confirm the reason why the patient has come to you. This becomes super helpful when you’re figuring out the management. As a bonus, it allows you to address the exact concern the patient has.

    Let them know you are on their side

    This is the turning point in the consultation. You have heard the patient. You have understood their concern. You now win their trust by telling them that you are there to help them. And then you start talking a bit.

    Ask your questions

    You should have held the questions in your mind till now. The time to start asking them is now. Start with clarification of symptoms. Ask for negative history. Ask about comorbidities. Ask about past history, family history, socioeconomic history, and so on.

    Asking negative history

    For asking specific negative history, you’ll need to know about diseases. But there is a way to avoid that pre-requisite. Go from head to toe. (You’ll need some anatomy, physiology knowledge). 
     
    Look at the head and ask about all the organs that you see. Bonus point if you touch their head when talking about the head. (But that’s not always appropriate. Use your gut sense). Ask how their sight has been, how their hearing, taste, smell has been. Have they had cough, cold, throat ache? Then look underneath the skull. How has their memory, sleep, thoughts, etc been? (There is hair, tongue, teeth, and so many finer details I’ve skipped for brevity. You will have to be careful not to ask too many questions too. This is just an algorithm to generate questions mindlessly. Filter those questions by applying your mind.)
    Then go down to the chest. There are lungs, heart, esophagus, neck + thyroid. Ask questions about things that could go wrong there. Then the upper limbs.
    Then the abdomen/pelvis. These have so many organs. Liver, spleen, kidneys, adrenals, pancreas (endocrine, especially), and the alimentary tract per se. And depending on your patient, uterus, ovaries, so on. It is easy to forget the back with spinal cord.
    Then there are genitals and lower limbs.
     
    Then there are some general things like fever, bodyache which don’t really fit into this organ by organ thing but they usually come up somewhere in between.
    This is only one way to generate questions. Depending on how much differential diagnoses you have in your mind based on chief complaints, you might be able to come up with questions without using this algorithm.

    Other histories

    The best way to take history like past history, socioeconomic history, etc is to imagine yourself in the patient’s life. What is this person? Where are they coming from? Where are they going? What do they do in their daily life? How’s their life like? What’s their family? What do they do after getting up from their bed till they go back to bed? Do they take some medicines? Do they go to hospitals? Do they drive a tractor? Do they work in three houses?
    This part of the history should ideally go like a conversation that has become really interesting and you “want to know everything about” the other person. But often we don’t have a lot of time to spend here. And it is inappropriate to spend a lot of time here. Just get a fair sense of each slice of your patient’s life.
    What has their relationship with themselves been? Do they treat their
    body and mind well? Do they consume alcohol or use tobacco? Do they eat
    well? Do they exercise? Do they work too hard?
     
    What has their relationship with their family been. Who is their caretaker? Could someone in the family be giving rise to their sickness? What’s the family dynamics?
    What has their relationship with the society been. Are they generally happy with life? What do they do in their life?
    What has their relationship with the medical system been. Do they have
    any diagnoses? Do they have any other doctors? How many times have they
    had significant medical care in the past and why?

    Summarize your idea of pressing issues back to the patient

    By this time you have gone far away from chief complaints and to bring the attention (the patient’s and yours) back to it, you can summarize what you think is the problem the patient is going through to them. And then after you get the patient’s confirmation you can proceed to examination.

    Advantages and disadvantages of this method

    What I’ve described here, like other ways of history taking, is just a template. This one is focused on getting a whole picture of a patient’s life without using a lot of knowledge about diseases. Another advantage is that you can build a lot of empathy. But it is also very time consuming. It often takes 45 minutes to an hour just with the history if done this way.

  • Why Researchers Who Care About Equity Should Use Zotero (and Not Mendeley)

    If you are a researcher, chances are that you write papers. And if you write papers there is a good reason for you to use a reference manager (also called citation manager?). If you use a reference manager and you care about equity, there is a good reason why you should use Zotero.

    Why use reference managers?

    Because the publication systems used by most of your journals are (intentionally) ancient. The internet allows usage of hyperlinks on any word in your article. But the academic society is still worried about putting references in an order at the end of the article. And every journal has their own citation “style” (as if the font style of the journal name matters in the quality of the reference). While all of this is part of a system that wants to continue making creation of knowledge the exclusive privilege of an elite circle, sometimes you might have to be a part of that system. And you’re better off handing to a software the tedious (and useless) effort of keeping track of your references and arranging them in an order and in the right “style”.

    Also because when you’re doing literature review you might want to keep track of a *lot* of references and you might want to tag them, group them, share with others, etc.

    So, use a reference manager and never copy paste references manually.

    Why not Mendeley?

    You might look at the options and you might see this software called “Mendeley”. And you might think, “Ah, this looks like a good fit for my use case.”

    But did you know Mendeley is owned by Elsevier? Do you know how in the age of the internet Elsevier and many other publishers continue to charge people for publishing and for reading? Do you think that these are reasonable charges levied in return of some great effort from their part? If you think so, you have literally no idea how the internet works. 

    See you are reading this blog. It took me zero money to publish this post. And that cost would not have changed a bit if I had a 100 references at the end of this post. This gets published under a creative commons license and that didn’t change the cost from zero either. Once I publish it, I will share the link to it in social media and other places. And people can add comment under it. Remember that most journals don’t pay peer reviewers anything for reviewing posts either.

    So that should really make you wonder what the process of publication in journals are about. My philosophy about journals are simple. Journals give you credentials and privilege. So you publish on them. And the academic society considers publication in journals as the yardstick to measure your merit. And that vicious cycle perpetuates.

    But I understand your plight. Just because the system is horrible you can’t avoid the system. And you’re condemned to the life of a 20th century academician. Fine. Publish. But don’t support Elsevier, Wiley, American Chemical Society, etc. 

    And don’t use Mendeley which is proprietary and owned by Elsevier.

    Use Zotero.

    Zotero is free and open source software. I use free to mean “freedom” as in “free speech”. Zotero is released in a GNU Affero General Public License. Which means that all the source code of Zotero is available to anyone who wants to modify it, add new features, etc. 

    Newton said “If I have seen further it is by standing on the shoulders of Giants”. If knowledge was like proprietary software, Newton would have said “I couldn’t have seen further because the Giants had a license agreement that said that I should close my eyes if I were to stand on their shoulders” and we wouldn’t have heard about Newton either.

    Open knowledge lets everyone stand on the shoulders of each other and see farther. Free and Open Source Software (FOSS) lets new programmers write better software by standing on older software. Zotero is that.

    If you care for equity, you should start from where you are.  If you use and encourage Mendeley, nVivo, and so on, you are
    ceding control to a proprietary ecosystem where the rules are laid down
    by the software “owners”. If you use FOSS like Zotero, Taguette, R, PSPP, etc you are strengthening software that is collectively owned by human kind. And you are making life better for everyone.

  • How To Stay Sane Online in 7 Simple Steps

    The sheer vastness of information online can disorient some people. Fake news and hate makes it even harder for them. These techniques are what I personally use to keep my mind “blissful” despite what is going around me. And yet I get to enjoy all the goodness of internet too.

    #1: Be ruthless in cutting down

    You simply cannot let everything in. The internet is almost a billion people creating content every single day. And you are but one tiny human. It is impossible to follow everyone, it is impossible to subscribe to every channel. Cut down ruthlessly. Curate your life to exactly what you need and nothing more. Make your garden your own.

    #2: Use mute and block liberally

    Muting and blocking are tools designed to protect you. Use them! Block people who push unwanted things on to your face. Block them if they amplify hate. Block them if they give attention to attention seekers. Block them if they don’t understand how fake news spreads and are complicit. Block them if they are lying. Block them if they’re pushing their own image. Block them if their politics is that of selling fear. Block them if they sensationalize. If blocking is impossible (due to reasons), use mute. Prune weed from your garden.

    #3: Unfollow, unsubscribe

    There are so many platforms and so many content creators. You probably started following someone years ago when you were a different person. Don’t let your past hold you back. If you are subscribed to someone whom you wouldn’t subscribe to today, unsubscribe! You have grown, but the people you’re listening to haven’t? Stop listening to them and start listening to new people. Don’t stay connected with someone just because you went to school with them. Break connections. Create new connections.

    #4: Deactivate

    Some platforms simply are not for you. There are a thousand reasons not to have a Facebook account. TikTok exists only because most human beings are interested in sex. Deactivate and delete what doesn’t help you.

    #5: Avoid news

    There is a superb essay by Rolf Dobelli about news. Read it. News is like sugar. Unhealthy, toxic, and unnecessary. If you are using platforms to keep abreast with news, you’re doing it wrong in two ways – platforms aren’t the best way to listen to news, and listening to news isn’t the best way to spend your time.

    #6: Read books

    Books are serious. Books take time and effort. Books take research. Read books.

    #7: Use tools that give you control

    There are technologies like web feeds that put you in control. Use them. Take control.

  • What Patients Don’t Know About Medical Schools

    There are people who assume that doctors who get into medical school through reservation end up as bad doctors. They have no clue how medical school works.

    I won’t go into the reasons why reservation (or affirmative action) exists. That is one of the easiest ways for governments to “do something” towards inequity in the society. This post is about the relationship between medical school and bad doctors.

    Defining bad doctor

    Let’s first define a “bad” doctor. An objective way of measuring that would be – a bad doctor is someone who kills the most number of patients. There’s a problem with that though. A doctor with no patients would then not be a bad doctor. And a surgeon who takes on the most difficult cases (with proportionately higher chances of deaths) would also be considered a bad doctor. So, the absolute number of patient deaths is not a very good measure of the badness of a doctor.

    Maybe we can then take the subjective measure of “patient satisfaction”. The doctor who gets 1-star rating for most consultations is a bad doctor. That is tricky though. The doctor cannot keep only the emotions of the patient in mind. The doctor also has to worry about the medical issues. If a patient prefers that the doctor does not examine their abdomen, a doctor who is dealing with this patient’s “pain abdomen” may score poorly on patient satisfaction if the doctor does consider it important to palpate abdomen. Patients might be less satisfied if the doctor doesn’t prescribe them a few medicines. 

    If “patient satisfaction” is measured in a longer term wherein the formalities of a consultation are forgotten and all that remains is the satisfaction of achieving good health, maybe then it is a good measure.

    People in the profession can also score doctors. I could make up a criteria for scoring doctors. I could say the doctor who practices the most rational, ethical, and cost-effective medical care is the best doctor and vice versa.

    A hospital can say that the doctor who generates the most revenue for the hospital is the best doctor.

    Someone can say that the doctor who works the longest hours is the best doctor.

    It is thus clear that who is a good doctor and who is a bad doctor is a difficult thing to have consensus on. Let us nevertheless choose a popular vantage point.

    Let us call the doctors who are irrational in their care and leads to poor health outcomes as bad doctors. (I had initially included “insensitive to their patients” in that list, but apparently many of us elites think that the fictional (or not?) “Dr House” is a good doctor. So we will first talk about these “good” doctors and later come to whether there are alternate definitions of good doctors).

    Medical school training

    What does a medical school train doctors in? Indian medical schools (at least the south Indian universities I know about) confer MBBS degree on someone based purely on theory exams and practical exams with theory given more weight. The whole training for 4.5 years is focused on what those exams need. And how’re those exams conducted?

    Theory exams are mostly single sentence questions that goes like “Write a brief note on <insert health condition name>”. (You can see many question papers in the archives of this blog). There is no “Higher Order Thinking Skills” involved in MBBS theory papers. The only skill tested is that of ability to memorize a lot and write a lot more.

    Practical exams are slightly better. In the clinical subjects, there would be patients called “cases” who are examined on the spot by the candidate and afterwards an examiner(s) and the candidate discuss the “case”. These practical exams are not scored with an “Objective Structured Clinical Examination” pattern. Therefore, it doesn’t matter how you examine your patient or if you examine them at all, all that matters is that you have the right diagnosis and that you can discuss lots of points about that diagnosis with the examiner. In reality, often the diagnosis of the patient is “leaked” to the candidate before the exam and once that is known the patient is just a prop in the act.

    In summary, medical school tests you on how well you can remember the textbooks – and that alone.

    Does that mean all the training in medical school is towards that? No. There are some islands (in form of an exceptional lecturer, post-graduate or peer) where other skills are focused on. But to a large extent medical school training is towards what is tested.

    In reality, medical school training does not help people perform good even in these tests because medical school training is literally paid doctors who have no philosophy on teaching (let alone facilitating learning) passing their time with by wasting the valuable time of learners. If medical school professors were sent to teach 12th standard biology classes, their students would dropout and re-join 11th standard in the computer science stream.

    (Of course there are some really good people. And the bar is so low that even someone who talks to their students with kindness are considered good professors in medical school. Anyhow, let’s not be bogged down by exceptions)

    How are doctors made then?

    Doctors become doctors not because of medical schools, but in spite of medical schools. It is mostly their interaction with textbooks, peers, patients, and life in general that makes them doctors. And only because the law restricts this opportunity to the confines of medical schools, it is restricted to medical schools.

    The skills involved in patient care – communication, courage, critical thinking, empathy, leadership, etc have nothing to do with medical school training.

    The theoretical knowledge involved in patient care are all textbooks based.

    Procedural skills are learnt by doing (on real patients) with some supervision and there are no special courses to improve or learn these skills in a setting where it is okay to make mistakes.

    Where do doctors really learn their craft then?

    MBBS doctors start learning real medicine towards the end of MBBS (on their own). They get really good at it only after MBBS – either by working as a postgraduate student or by working in hospitals.

    And these opportunities to learn after MBBS are really diverse and heterogeneous. Some work as residents in certain specialty departments where they learn a lot about those specialties (and a bit about medical care in general). Some do this with a gap of a few years (spent in PG entrance preparation).

    From then on they keep getting better at it. Because every new patient they’re responsible for teaches them something new.

    In essence, the 5 years in MBBS has little to do with how good/bad your doctor is. Medical school is a place where doctors learn about the outline and the syllabus of MBBS. After graduating is where they learn to treat people – and that is what decides how good your doctor turns out to be.

    What makes a good doctor?

    Privilege plays a role. If one has the privilege to get trained abroad (or in India) in medical schools that are interested in pedagogy, ethics, and rationality, there is a good chance that they learn to become better doctors. Also if one has the privilege to afford to work with lesser known good doctors within India, again there is a good chance that they learn to become better doctors.

    Scientific temper and critical thinking plays a role. I’m not really certain how one gains these skills. Life experiences that makes one skeptic may help, perhaps? Or reading about science might help too.

    Empathy and emotional intelligence plays a role. Understanding one’s patient and their context is critical to be able to understand what they’re saying. Often the patient is telling the doctor the diagnosis, but the doctor can’t hear because they cannot connect.

    If you’re under the impression that performance in an entrance test is what makes a good doctor, you’ve gotten it completely wrong.

  • Want to Predict COVID? Ask the medical officers or lab managers

    From the beginning of this pandemic I’ve had very accurate predictions of COVID surge, lull, and fall from two kinds of people – PHC medical officers and lab managers.

    The PHC medical officers see anywhere upwards of 200 sick people per day and they get to see how many people are coming in with COVID like symptoms and notice patterns before they are even tested.

    The lab managers keep a track of test positivity rate (and test rate) and can sense that it is getting overwhelming vs underwhelming.

    The only kind of people who haven’t particularly been helpful are the people who draw graphs based on numbers from government sources.

  • Three Stories On Connecting Health Data

     Story 1

    There was a small research institute with 20 people. Someone among the staff did an online survey to ask everyone their demographic details (name, age, gender, email address) and their diet.
    After four months, another person ran another survey. By then there were 23 people in this institute. This surveyor asked everyone their name, email address, haemoglobin.
     
    Now the director of the institute wanted to connect diet to haemoglobin levels. So they took up the older survey and assumed that since email addresses will probably remain the same, they could use that field to “connect” these databases together. But, alas, there was one person who changed her email from @gmail.com to @institute.org
     
    But never mind. They knew who it was. So they just fixed this by copy pasting rows in a spreadsheet.
    Story 2
    A survey was done in 20 villages. There were two teams of 5 data collectors who divided the villages equally. They went to households and collected from the people demographic details, answers to a lot of questions about health, and also the GPS location of the households.
    Then, 5 months later, the PI got more funding to do a haemoglobin study for 600 people. The PI decided to divide this fund in such a way that 300 people who come to a nearby hospital would get tested and 300 people from the previous survey (6 villages) would get tested.
     
    One of the previous data collection teams was called in. Turns out 5 of those villages were surveyed by the same team in the past. Fresh from the previous survey, they went to these villages and quickly located the households they had previously surveyed. Once they were in, they used the names of the individuals to locate their past record from the surveying app and added haemoglobin values too. But in some households there were no people as they had gone for work.
    In the remaining one village, they used the GPS location to find out the households. It was slightly harder, but it was doable because the application with which they collected the data could directly point them to the household location. It worked when the GPS would work. When the GPS wouldn’t work, they would look at the names of the people in the households and ask people whether they knew where those houses were. Somehow they made it work.
     
    In the hospital, meanwhile, some of those missing people from these villages had come and they were getting haemoglobin tests. But this data was not being collected.
    Story 3
    The Government of Karnataka decided to do tribal health research. They collected data (demographics, height, weight, BP). Then they assigned to each individual a unique ID number. Something called Namma-ID. They told them that they should keep these Namma-ID numbers safe and that these would give them benefits in healthcare, etc. And someone in the government had the idea that the data they collected should be available for researchers. Any researcher who signs a confidentiality clause would be given all the data (name, father/husband name (still patriarchal in 2021), home address, village name, Namma-ID, etc included). There was one doctor in the area who got themselves access to this data. This doc narrowed down the data to their own village and the set of people with hypertension and saved that in a spreadsheet. 
     
    Every time someone came to their clinic, the doctor would ask if they had a Namma-ID and if so the doctor would look at their height, weight, and BP from the GoK data. If they didn’t bring their Namma-ID, the doctor would ask their name and try to search. Sometimes the doctor would have to try various spellings to get the right person’s record. But somehow the doctor would find the right record and add more details when that particular visit was over.
    Then there were times when people who were new to the village came to the doctor’s clinic. The doctor would spend minutes searching for this new person’s record. The poor villager would be sitting on the patient’s chair wondering why the doctor wasn’t asking any question about the health issue.

  • Organizations, Like People, Have Values

    I stole the title from Peter Drucker’s Harvard Business Review article titled “Managing Oneself” [pdf]. It has been 4 years since I graduated medical school and in that many years, having worked with (and escaped having to work with) organizations of different kinds, I have come to the same conclusion.

    Organizations have values. These values can be determined by observing the way the organizations work. Whether or not you will feel happy working with an organization is determined by whether your values are compatible with the value system of that organization.

    The values of an organization exist independently of the values of people in its leadership. The leaders have a great role in determining the values of an organization. But often leaders are distracted by a “pragmatic” approach that usually follows money in an increasingly capitalistic world. And this makes them make compromises without even realizing what they’re giving up.

    And you can’t blame them. Organizations, by definition, have the motivation to grow. Growth is easier to achieve if an organization focuses on either money or power. Because they have a top-down nature, it is easier to wield money and/or power to direct growth. There might also be an argument that a top-down approach like that will lead to larger and faster results too.

    This also leads to a particular set of values. Even if the leaders of an organization have a different set of values in their personal life, their choice to focus on money/power will lead their organization to have a value system in which retaining and increasing money/power will be a core priority. That influences the kind of values that can thrive in those organizations.

    On the other hand, choosing to focus on things like “people” will lead to organizations being structured in very different ways, especially with regard to decision making. Such bottom-up structure fosters different values altogether.

    When I say bottom-up, I am not talking about a “top-down disguised as bottom-up” management structure. In fact, the right way to run any organization is that top-down, yet bottom-up way as explained in this article: “How to Design a Self-Managed Organization“. But eventually such an organization is still one where there is a leader who ultimately is in charge (even though they rarely use that control in day-to-day activities of the organization). I am not talking about that bottom-up style.

    I am talking about a truly bottom-up style where there are no leaders at all. This is akin to participatory research. 

    “Participatory research comprises a range of methodological approaches and techniques, all with the objective of handing power from the researcher to research participants, who are often community members or community-based organisations. In participatory research, participants have control over the research agenda, the process and actions. Most importantly, people themselves are the ones who analyse and reflect on the information generated, in order to obtain the findings and conclusions of the research process. ” ~ source

    What would organizations look like if they embraced the participatory approach? What would the role of a leader be in such an organization?

    The P2P foundation wiki has lots to speak about it. On the same, I found a link to The Three Ways of Getting Things Done by Gerard Fairtlough. This book provides two alternatives to hierarchy – heterarchy and responsible autonomy. 

    “If hierarchy is the power system of centralized systems, then heterarchical power is the power system of decentralized systems and Responsible Autonomy is the power system of distributed systems.”

    Similar thoughts about adaptive leadership is mentioned in Complexity Leadership Theory (H/T: Dr Ramakrishna Prasad).

    The question of money or “business model” also has a big role in deciding the values of an organization. Organizations who raise money before work is done tend to have made promises which decide how the work is done. The nature of these promises decides the value of these organizations.

    Sometimes, such commitments can make an organization take up values that are antithetical to their own mission. Especially when it comes to free software, or free knowledge, having financial commitments lead to organizations wanting to make money out of software and knowledge – which is arguably easier if you restrict freedoms.

    An organization with the wrong structure cannot have the right values. And if you find yourself in a situation where the people in an organization wants to have the right values but aren’t radically restructuring the organization, then run away as fast and far as possible.

  • Whose Responsibility is Health?

    How do you trigger a never-ending debate on Twitter about health? You have two options. Either talk about a bridge course from Ayurveda into modern medicine. Or talk about compulsory rural service.

    Why, though? The superficial reason is that Twitter is a stupid medium where there is not enough space to make a nuanced argument. The deeper reason is that it is not clear whose responsibility “health” is. And that’s because there are two ways of defining what “health” is.

    There are folks who take health to mean absence of diseases. Even when the community medicine department in medical schools keeps talking about WHO definition of health, many medical graduates focus on “diseases” because the rest of the medical school talks only about diseases. This percolates to the rest of the society and in the overall society there is a clear notion that health is the absence of diseases and that healthcare is access to curative services.

    The impact of this definition is most strikingly visible in what people coming out of medical schools tend to do with their lives.

    They seek specialties and super specialties (like interventional radiology, dermatology, and cardiology). They do not have a problem in spending one, two, or three years in trying to get post-graduation seats. They seek work in the largest hospitals in the largest cities. They make their life about “diseases” and restrict their role to providers of disease-curative services.

    But this definition is not just restricted to doctors.

    • Faculties in medical schools continue to teach students that health is about “diseases”. (Even in some community medicine departments).
    • Government of India spends a significant share of health budget on setting up/upgrading hospitals and on reimbursing curative services through elaborate insurance schemes.
    • When there is a pandemic, technologists rise up and try to “help” with their mathematical models. But they don’t think they have anything to do with health during non-pandemic times.
    • People think about health only during bouts of illnesses. They pay for healthcare only in the context of curative services. (Or insurance premiums for schemes that apply only to curative services).
    • There is no talk about health during election campaigns.

    There is a wider, (arguably more “real”) definition of health – as a “state of complete physical, mental and social well-being”. This is often forgotten. As per this definition, we have country full of unhealthy people. And people who stick to this definition make the case that health has as much to do with the society and its politics as it has to do with hospitals.

    They argue that education, opportunity (to make a living), dignity, equality, rights against exploitation, justice, access to technology, and so many other factors go into deciding whether individuals are healthy.

    When it comes to doctors (and other medical professionals), they have two ways to spend their lives in this society.

    1. Follow the narrow definition of health where all that matters to them is the survival of their “patients” – those who come to the hospitals.
    2. Follow the broader definition of health where they are leaders and change makers and politicians and advocates.

    Unfortunately, in the never-ending cycle of disease management and education to manage diseases, most of our medical professionals (doctors, nurses, etc) are not trained to take on the broader definition of health as their “job”. Which leaves them restricted to following the former kind of life.

    The broader definition of health is then left for a very small set of people to work on. They are variously known as “public health professionals”, “family physicians”, “primary care practitioners”, “community health specialists”, etc.

    The task for this small group of people, on the other hand, is humongous. While delivering curative services require to match demand with enough supply of resources (human and non-human), working on the larger definition of health often needs a whole different approach. For, the problems in (social (?)) determinants of health like gender, class, education, economic condition, and so on often require action beyond individuals and institutions. Some of these work span generations. And there is no linear progress. Sometimes societies regress to worse conditions too.

    Now, here is the problem. This bigger task should not be and cannot be done by “medical” professionals alone. It requires collaborative action from communities, lawyers, politicians, engineers, economists, artists, historians, every person imaginable. Because that work is not related to “medicine” alone.

    Now, let us look at the controversial topics that we started this post with.

    In both bridge courses and compulsory rural service what the governments seem to be trying to do is to increase the number of “qualified” doctors (and hopefully other medical professionals) in rural areas. We can assume that their assumption is that if there are enough trained curative service providers, there will be some respite.

    And they are probably not a 100% wrong in making that assumption. If a person with wisdom and training goes to a place that can benefit from that wisdom and training, that place will benefit at least a bit. (Taru Jindal’s story is an example).

    But there are some important counter-arguments

    • The nature of these policies are sometimes objectionable. “Mandatory” rural service is as controversial as mandatory military conscription. Bridge courses may often be seen as unscientific or unfair.
    • The training in medical schools (especially when they get more “specialized”) need not be tuned to the context and needs of rural communities. Even if medical professionals are trying to deliver only curative services, they can be quite disoriented when they find that they don’t have the investigations and interventions they need at arm’s length.
    • To stress on the point of training, there probably is very little of leadership training in medical schools and often in communities where the health system is next to nil leadership is a critical element in being able to set up systems.
    • The kind of leadership challenges one faces in rural communities could be different, and the solutions might often require larger systemic changes (refer the broader definition of health).

    It is counter-productive to train a generation of medical professionals in delivering curative services in cities and then expect them to perform in a broader, entirely different, and disproportionately more challenging role as health care leaders in rural areas. 

    You can send them to well functioning hospitals with all facilities in rural areas and they probably will find their groove. The irony is when you are sending them to rural areas to build such hospitals and/or systems for health without giving them any training in that.

    And it is not all medical school training that I’m talking about. It is also the societal training. We as a society are training many professionals (doctors, engineers, included) with a very narrow definition of purpose and meaning ascribed to their profession. If you are a doctor – the meaning of your life is to treat the sick. If you are an engineer – the meaning of your life is to plan and build things. And so on. When have we, as a society, encouraged people to ask larger questions. Like “Why are people falling sick?”, “Why does this thing have to be built?”, “What is my role in perpetuating the system the way it is?”, “How is it possible that there are widespread inequities in the world while there are enough resources for all humans to have a dignified life?”, “How are our decisions and actions endangering the survival of this planet?”, “What is the relation between care for others and democracy?”

    The questions that matter often have solutions that require collective action. And that often includes many kinds of individuals (no matter what their “job” or “background” is) to take action. Sometimes that includes you. Do you consider that as your responsibility? If you do not, then you are part of the problem.

  • Don’t Cook Your Meals

    Thanks to The Great Indian Kitchen a lot of discussions are happening on cooking. I wanted to note down a few of my thoughts in relation to cooking, etc.

    I find cooking boring

    There might be people who find cooking interesting. I am not one of those persons. I find food boring too. Anything healthy and tasty is good food for me. Probably that’s why I find cooking boring. Because cooking is about food.

    Cooking regularly for oneself is a massive waste of time, money, and energy

    This is especially true for people who have other engaging work to do – people like programmers, teachers, etc. Cooking regularly takes away a large amount of time from your daily life which you could have spent on reading, learning, etc.

    In the video above (in Malayalam), around 15 minutes, Maithreyan also tells something to this effect. On the economics of cooking.

    Mass production of cheap and healthy food should be a reality

    In VMH, I used to eat from the canteen three times a day. I was never starving and even though I missed chicken and beef, I was eating okay. I lost the 4 kgs I gained during internship eating Biriyanis all day. But once I moved to Bangalore, I couldn’t find a replacement for this canteen.

    Zomato/Swiggy etc are a problem because of two reasons

    1) The amount of plastic.
    2) The cost because someone has to burn petrol and drive a motorcycle all the way from the restaurant.

    The hotels were all catering to the occasional outside diner and would cook expensive and often unhealthy dishes.

    Hiring the service of a maid is good for many reasons

    For a long time I used to feel icky about hiring the service of a maid. Perhaps I didn’t think a lot about it. I used to feel that it is wrong to rely on someone else for one’s basic needs like food, cleaning house, etc.

    But during COVID when people were all losing jobs and we were literally asked by someone at the local bajji shop whether we needed house help, Swathi and I decided it is time we hire someone’s service.

    And then I figured out how by redistributing money through such hiring is actually good for everyone. It frees my time and mind. It gives someone who would otherwise be unemployed a chance to do work.

    Cooking can do with a lot of innovation

    Here’s a recent talk I enjoyed watching.

    It talks about how bras have remained the same for over a century. Perhaps cooking is like that. At least home based cooking. Nobody has thought about revolutionizing cooking. Sure there are innovations like mixers, grinders, and my all time favorite – rice cookers. (Fun fact, did you know the rice cooker works by the principle that water when still boiling cannot exceed temperature of 100°C? The thermostat of a rice cooker cuts power off when the temperature exceeds that because by then there wouldn’t be any water left as liquid).

    But we haven’t redefined cooking the way cloud computing has redefined servers or the way ebooks have replaced libraries. Maybe some day we will find food pills and that will be it.