Blissful Life

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

Author: akshay

  • What’s the Most Important Scientific Research?

    Post-facto rationalization. That’s something human beings are good at. If you decide to do research in a specific field, you’ll come up with hundred ways to justify why that research is important, if not the most important.

    I have been listening to Ravikant Kisana the last couple of days. In the podcast episode about Chandrayaan, RK calls Chandrayaan “completely useless”. A summary of the episode is the description of the episode: “Buffalo wonders what the Chandrayaan benefits are, while pondering over the crumbling education system. We take a moment to acknowledge the hot mess that is Gen Z.”

    Palani Kumar makes a very similar point in the talk about manual scavenging in CMC Vellore. “We have too much technology, we have lots of technology, we went to moon also, the other side of the moon, we haven’t saved anyone’s life among manual scavenging people”.

    I’m part of Sarvatrika Arogya Andolana – Karnataka which makes the consistent demand that we need to put more money into primary healthcare and have free medicines in government hospitals and so on.

    That’s the context in which I come across this thread by Nandita Jayaraj about a couple of breakthrough researches. Before I finished reading the thread I tweeted about it: 

    “Reading this thread made me think about how scientists in their lab coat are viewed in a very neutral or positive way by me whereas some of them are quite cunning and will do anything to get funded. 

    There are so many scientists hyping up rare diseases because that is where they get money to play with genes.”

    I hate universities. A lot.

    It is easy to argue with me by saying that universities are important and they create safe space for learning and that I can reject universities because of my privileges, and so on. But my intense hatred for universities has been validated by Ravikant Kisana in the Mind Your Buffalo podcast about institutional murders. The universities and the academia and the intellectual elite of this country are indeed a big part of the problem.

    And that’s where I come from. A position of intense hatred for scientists for their ignorance of how they’re part of the problem.

    And then these people who are held in high regard, in general, by journalists, people, and everyone, talk about research. From their pure and apolitical viewpoints. All I can hear when they open their mouth is “I want money. I am so smart. I do the most important work on Earth. Give me money.”

    Let us set all of that aside and look at this question “objectively”. Isn’t this sort of a trolley problem? You’re forced to choose between space science and sanitation technology. You’re forced to choose between rare diseases and common diseases.

    One could say “let us put some money in everything” because that’s one way of thinking about it.

    One could also think in purely utilitarian ways and calculate the cost (somehow) of each and measure benefit and do some kind of optimization.

    One could operate purely on empathy. But that has its own problems (Malayalam talk).

    Anyhow, answering this question is very hard. But it is indeed possible to look at it from a lens of caste, privilege, etc as seen above in RK’s podcast.

    (more…)

  • What Ails India’s approach to Universal Health Coverage is Elite Solutions That Have No Basis in Reality

    “Poorly maintained registers of doctors”. That’s the first five words of the article What ails India’s approach to Universal Health Coverage in Times of India by four people from Vidhi Centre for Lobbying Legal Policy. Let’s talk about that after we look at universal health coverage.

    “Universal health coverage (UHC) means that all people have access to the
    full range of quality health services they need, when and where they
    need them, without financial hardship. It covers the full continuum of
    essential health services, from health promotion to prevention,
    treatment, rehabilitation, and palliative care across the life course.” ~WHO

    That’s quite an ambitious goal, isn’t it? People having access to a full range of health services where they need them, that too without putting them in poverty.

    The community medicine HoD of PGIMER, Chandigrah ends an article about achieving this as:

    “In summary, to achieve the universal health coverage, major challenge in India is promotion of health, prevention of diseases, and provision of health care in a balanced manner, which will require innovative public policies, strategies, and programs in many sectors. Development and implementation of a multisectoral approach to achieve sustainable development goals is the need of the hour. Establishment of a Public Health Commission will go a long way in achieving coordination of various initiatives not only in the Ministry of Health and Family Welfare but also in many other relevant ministries/sectors. At least 5% of the gross domestic product should be earmarked for public health and a responsive governance mechanism as outlined above should be set up, to achieve universal health coverage by 2030 as envisaged in the United Nations sustainable development goals which are also endorsed by the Government of India.” (emphasis mine)

    Jan Swasthya Abhiyan, the Indian version of People’s Health Movement, suggested in 2012 a national debate, while also saying that “providing entitlements must be accompanied by a clear framework for accountability and grievance redressal” and that “highest priority must be given to significant expansion and improvement of public health services”. (emphasis, again, mine)

    The Lancet lobbying group for “reimagining India’s health system” in a theory of change also talks a bit about accountability.

    “Finally, the fourth proposed intervention relates to creating accountability and trust in public and private health systems. Enhancing the scope of political engagement is a crucial step toward this, along with developing and disseminating performance reports on the functioning of various health systems. Communities should be able to conduct social audits of the health systems they use along principles of Community-Based Management (CBM). Establishing or strengthening the legal framework to protect and empower communities would also be essential, and a robust grievance redressal mechanism should penalize malpractice and negligence. However, care needs to be taken to ensure that caregivers are not unduly penalized.”

    One could indeed say that accountability and grievance redressal forms, or ought to form, a part of the path towards universal health coverage.

    And that’s indeed what Vidhi set out to study as per the three reports they released on Dec 5 all of which start with “Holding Healthcare Providers Accountable”:

    And the next paragraph in the TOI article makes it abundantly clear that they’re indeed talking about these: “Healthcare providers in India are held accountable by the state through four primary mechanisms — courts, consumer fora, medical councils that regulate healthcare professionals, and regulators of clinical establishments”

    This is where I begin to disagree (and this is probably where my shock comes from in reading that “poorly maintained registers of doctors” ails the approach to UHC).

    When the rest of the world is talking about holding healthcare providers accountable, they’re talking about the healthcare providers being held accountable by people, society, or basically healthcare consumers. For example, in the Lancet group’s article above, they talk about social audits. But when Vidhi is studying this, they put on an irrelevant criteria — “by the state”.

    If they meant state in a larger scope wherein state includes citizens (people, society, and healthcare consumers), then they’ve gravely erred on the “four primary mechanisms” through which healthcare providers are held accountable in India.

    When one glances through the report this becomes obvious as they have very nicely documented the numerous reasons why all of these fail to hold healthcare providers accountable. Here’re some statements from their three report landing pages:

    • “the apparent reluctance of courts to convict healthcare providers of medical negligence under criminal law raises questions as to the role of this mechanism as a tool of accountability in the healthcare space”
    • “However, SMCs fail to perform their adjudicatory functions effectively. Very few complaints are instituted, and even when instituted, the most common disciplinary actions are warnings or mandating attendance of continuing medical education (CME), with very few instances of an RMP being removed from the register either temporarily or permanently.”
    • “Enforcement has continued to be unsatisfactory in various states that have adopted it. The Act also has various gaps, like the absence of grievance redressal systems, that prevent it from being an effective and patient-centric healthcare regulation. “

    Yet they have persisted in their belief that these are the “primary mechanisms” of holding healthcare providers accountable.

    If their argument is that they’re only researching how the “state” can hold providers accountable, then there is a case to be made that “holding accountable” is not a function of the “state” — which in many cases is the “provider”. The state itself has to be held accountable (at least in the case of public healthcare system). “Holding accountable” is almost always the function of consumers and citizens.

    If their argument is indeed that these are the main mechanisms, and they’re wrong, then what are the real primary mechanisms of holding healthcare providers accountable?

    I have written about this before where I talk about avoiding legal system altogether. I write in that that we could focus on activism, politics, journalism, and research.

    But what are the “primary” mechanisms?

    Let’s put ourselves in the shoes of a healthcare provider.

    An independent private healthcare provider running a clinic. What they’re the most afraid of is a patient dying and people thrashing their clinic. The mechanism of accountability here is direct physical action.

    An HCP inside a private hospital. They’re most worried about the person who pays them salary. And that person is most worried about the reputation of the hospital being ruined by reports of inadequate care there. The mechanism of accountability here is social messaging.

    An HCP inside a public hospital. They’re mostly not worried about anything. But they are indeed answerable to their medical superintendent and district level officers (like the DHO) who have the power to transfer them. And these higher officials are most worried about politicians (minister, MLA, etc). And they’re the most worried about their political image being tampered by journalists writing up a series of negligent care in government hospitals.

    Through this exercise in empathy what I’m trying to say is that the biggest (primary) mechanism of holding healthcare providers accountable is “social pressure”.

    But Vidhi is a group of lawyers. The four authors of the TOI article are lawyers. And all they can see this is as a problem of law. They can look at it only in terms of clinical establishments act, and tort law, and NMC act, and so on.

    That’s absolutely fine. It is very much required to have well functioning regulatory mechanisms through law.

    The problem is when they claim they know more than what they know. You don’t reach Universal Health Coverage by focusing on law alone. And I don’t even want to go into how “poorly maintained register of doctors” has relatively little to do with holding healthcare providers accountable through law.

    But all I want to say is that Vidhi should stop writing TOI articles that help Nandan Nilekani build data maximization projects like the NDHM.

  • Imaginary Heroes and Why A Radical Commitment to Truth is the Only Solution to Inequity

    Imaginary Heroes and Why A Radical Commitment to Truth is the Only Solution to Inequity

    In my post about truth and Gandhi, I wrote about how a radical commitment to truth is the missing ingredient in the world today. In this post I will elaborate on that. To do this, I’ll first recap what it means, then talk about the “inverted iceberg” model of savarna mediocrity, and finally illustrate what a radical commitment to truth would look like in practice.

    Truth: a recap

    To know how powerful is truth one just needs to walk the path of a truthful person for a while. It is an incredibly powerful philosophy that’s accessible to everyone. A radical commitment to truth as I described with examples earlier, has three components.

    1) Being in touch with your emotions and feelings, and showing commitment to try to label them accurately.
    2) A commitment to yourself to not invalidate your own feelings. To not act in ways that go against your feelings.
    3) A commitment to follow-up on things that you are uncertain of – so that you can arrive at the truth.

    This requires conviction and courage. And it provides immense strength.

    It is easier to explain why this is “radical” by looking at the society as we have it today. A great example is provided in Ravikant Kisana’s article “Saving the World Like a Savarna”:

    In the first few weeks of my doctoral studies at MICA, Ahmedabad, the professor was teaching us about Paulo Freire and the “Pedagogy of the Oppressed,” waxing eloquent about how the modern education system dehumanizes students and erodes their confidence daily. My cohort, though overwhelmingly Savarna, nonetheless had a few scholars from small towns. They didn’t have “good English” or “cultural polish” and struggled to follow the ornate vocabulary of our Brahmin professor. By this point in my life, I had mastered enough of the Savarna culture to pass off as “polished” and wealthy to their casual gaze.

    One day, in the privacy of her cabin, the same professor ranted to me about my cohort-mates, saying she could not believe how some of them had been admitted to the program and was counting on me as a “bright light” to get her through the course. I was shocked and struck by the contrast between talking so passionately about marginalized students’ issues in the lecture hall and making mean-spirited jibes at the same students in her office. In an immature move, I told the professor off and walked out. It immediately soured our equation and she, along with her husband who later became the Director of MICA, proceeded to bring the might of institutional hostility upon me for years, the effects of which still follow my career.

    This, Ravikant Kisana explains, is what is called “switching”. RK defines it as “the social behavior where Savarnas can pose as extremely radical and culturally progressive and then, with the flip of a metaphorical switch, slip back into their privileged family lives without the slightest existential friction“. RK further goes on to describe this like this: “Such posturing that borders on social deception is a public role to be played, a curation, a “look,” an outfit of sorts to mask what is fundamentally a conservative social core that is extremely difficult to unlearn“

    We could explain this in terms of truth (or the lack of it). The savarnas who do switching are living a lie. They are out of touch with their “inner core”. They fail to label their own feelings (1), they fail to act according to their feelings (2), and consequently they have no need to look for the truth(3).

    The solution to this would be to invert this lie and switch to truth. Before I illustrate that, let us look at how this “switching” is internalized by the whole society and how that is damaging the way we do anything.

    The inverted iceberg model of savarna mediocrity

    When we look at an iceberg, what do we see? We see the tip of an iceberg. About 90% of an iceberg is underneath the water. 

    Here’s the artificial picture of a full iceberg. Created by Uwe Kils (iceberg) and User:Wiska Bodo (sky)., CC BY-SA 3.0, via Wikimedia Commons. If you actually look at the physics, iceberg wouldn’t float this way as the stable orientation would be different.

    This iceberg model is applicable to human beings also. When we see a human being, we’re only seeing the tip of their unique lived experiences and life stories. Each person is at least 10x times more than what they are able to express. But, as is with icebergs, most people’s true worth goes unrecognized. We see the tip of the iceberg and we narrow the person down to that tip. But we can sometimes be reminded about what’s hidden behind the surface.

    This model accurately captures how most people get viewed by the society.

    But in the case of savarnas*, the iceberg is inverted!

     * Please note two things. One, I am using the word savarna as an umbrella to stand for elite selfish people. Two, in many ways I myself am a savarna.

    The savarnas are so loud, so much interested in talking, and hog up all the space. When this happens, rational people think “Oh, they must have a lot more to say and that’s why they’re speaking so much. Perhaps I’m only seeing the tip of the iceberg. I better see what more lies beneath the surface.” And this leads to them getting more and more space.

    Then, they repeat the obvious, they talk about the clichéd, they keep talking without saying anything.

    The savarna icebergs are inverted. What you see is all that is there. There’s nothing more than that.

    When savarnas do heroic things or give inspiring talk, they are at the end of their wits. When they make “deep” intellectual points, they’re talking from the maximum depth they can reach. There’s nothing more in them!

    But unfortunately we imagine that there is more. We create heroes out of them. We extrapolate their arguments and see them as bastions of hope and justice. We build imaginary heroes.

    I don’t want to name anyone, but if a savarna hero has ever shattered in front of you, you know who I’m speaking about. We thought they would do something because we built up a larger than life hero based on something they did/said in the past. And turns out we were wrong. We were too kind. Our hero was imaginary.

    How does a radical commitment to truth make things better?

    In a radical commitment to truth, we call out the mediocre as the mediocre. If there’s discrimination going on and ABC speaks against it but the discrimination still continues, we say “ABC spoke against it. Nothing changed.”. If there’s an organization that has worked 40 years in a sector and all they have managed to achieve is award after award and no justice, then we say “Well, this organization did work on this for 40 years and what they did is this much [only].” If there’s a savarna group which does the bare minimum, we say “Well, this group did the bare minimum”.

    We stop using the words “great work”, “admirable”, “amazing”, “super”. Let’s reserve the superlatives for the superlative. Let’s use mediocre adjectives to describe the mediocre.

    When an insanely privileged person does a PhD on something and comes up with a repetition of what’s already widely known, we call it “they have used their privilege to get a PhD by working on a topic and discovering nothing new”.

    When there’s a random new technology with no use coming out of an IIT, we say “these people with all the resources spent on them have come up with a technology that benefits nobody”.

    When a doctor treats their patient like a human being, we say “well, the doctor treated the patient like a human being as they should be”

    We start doing this and then we will be reversing a trend that has led to marginalization and oppression of a large majority. We will lead to a society where chasing (often fake) numbers instead of caring about people is questioned. We will challenge the capitalist assumptions of putting “efficiency” (read “profit”) above human welfare. We will challenge “merit”. We will destabilize the self-centered argument of “compromising for the sake of career”. We will put an end to the pragmatism vs idealism debate. (What’s preventing the ideal from being pragmatic?)

    We will stop being content with arbitrary measures of “impact” and we will settle only for equity and justice. We will stop glorifying the bare minimum. We will start demanding what’s right. We will rethink who we fall behind and whose voices we amplify. We will stop hero worship and rediscover the value of every individual in the community.

    And in that radical commitment to truth, we can be fully free. We can live our lives to our true selves. Often we will be forced to change. But there’s no reaching the truth without change. A radical commitment to truth is a radical commitment to change.

     

    Preemptively answering some questions

    How does this help?

    It forces us to improve. It forces everyone to improve. It creates an environment of growth.

    It also puts on display privileges and the contribution of those to people’s “achievements”.

    It creates a “level” discourse where the privileged doesn’t keep accumulating more privileges.

    Isn’t this discouraging for those who are doing work?

    If you really care about justice and equity, you know very well that what you’re doing is not enough. And you would be happy to agree with anyone who says how the world needs to improve.

    But shouldn’t we appreciate any step towards positive social change?

    We should. Our appreciation ought to be commensurate with how big the step is. It is the extrapolation and the superlatives that need to be avoided.

    By this standard, nobody will be doing good work

    Well, if we don’t apply these standards, we will keep getting the mediocre work that we have. Is that what you would like?

    Be comfortable with the idea that we can only be imperfect. Be comfortable with the idea of not having heroes.

  • Being Comfortable With the Non-Binary: A Code of Conduct Case Study

    Today morning I woke up to this message in FSCI‘s chat room:

    What happens here when a member reveals themselves to be a transphobe in another room? 🤔

    I immediately said “COC applies”. The FSCI code of conduct, which I have contributed to the making of, is very clear about keeping FSCI an inclusive space. It explicitly recognizes that gender identity and expression can be diverse. And someone gets called a “transphobe” typically when they go against this idea.

    But then there was this other question that came up in my mind. Would FSCI’s code of conduct apply to another room?

    My first instinct was to read through the actual code and look at the sections where it discusses the scope of the code: “all of this community’s spaces, including public channels, private channels and direct messages, both online and off.” There could be an argument on technicality as to whether another room could be considered as community’s space. There could even be a counter argument that the mere presence of another FSCI member in the other room makes it a private channel thus bringing it under the scope of the code.

    But I quickly realized where my “COC applies” comment came from. I wasn’t relying on technicality. I was relying on what I’ve internalized as the way a code of conduct works, and the way we influence others in the social organization.

    And that has got a lot to do with being comfortable with the non-binary mess.

    I was not like this earlier. I used to be very black and white, all or none about laws. I used to find comfort in the idea that anything human could be codified. Not just facts and information, but also implicit assumptions, emotions, social rules, and so on. So much so that I used to even think about building AGI with just symbolic AI through a comprehensive compilation of all these codified knowledge.

    But as I started learning more about the world and interacting with human beings in the “real” world, I started recognizing that many things about human society is much more complicated than what could be codified. I’m not talking about this being quantitatively so large that it is too difficult to codify. It is complexity on a whole different dimension that prevents codification.

    This complexity probably comes from free will. But what it practically amounts to is that there is no way to absolutely predict how human beings behave. (I leave it to the readers to draw parallels between this and quantum physics).

    This particular understanding manifests in two different ways in my thinking: intersectional and non-binary.

    I see the world in a heavily intersectional lens. Intersectionality is a framework that captures the many complexities of the world very well. It allows one to deconstruct (to use a word I used to hate) what’s happening without resorting to simplistic/reductionist explanations.

    But intersectionality without an understanding of the non-binary is a dangerous pitfall. Often what I see people doing is to think of intersectionality in a binary way, wherein instead of having a yes or no explanation, they would have a yes or no + yes or no + yes or no explanation. They would just superimpose multiple explanations. Easier to explain with an example. I had (more than) once heard a description of how a person who is queer and Dalit and Muslim suffer from “triple oppression”. This sounds a lot like someone trying to add up binary bits. That’s the antithesis of intersectionality.

    It is when you combine intersectional lens with a non-binary lens that you can see things more clearly and in more practical ways. In the non-binary lens not only do you see everything in shades of grey, you even see categories blurring. There’s no triple oppression when the very binary bits you are counting (Queer, Dalit, Muslim) cease to exist in well-defined boxes.

    Sounds like a mess? It is a mess. Maybe I’m struggling to explain this, and that’s okay. But non-binary is when you’re comfortable with the mess. (Hat-tip to Swathi who attended the Looking In Looking Out Workshop and gave me the word “mess”)

    Being comfortable with the non-binary mess is the key

    Incomplete information, inadequate resources, limited time. These are three things that make humans humans as opposed to Gods who are omniscient, omnipotent, and omnipresent. We are doomed to live this way. And we might as well be comfortable with it.

    The Code of Conduct is a good case study here.

    There are some people who feel a code of conduct takes away freedom of speech. There are some who believe that it is best to leave the code of conduct very simple (“Be nice” folks). The FSCI code of conduct is rather long. It is a synthesis of many other similar codes.

    What makes me comfortable with a code of conduct like this is that I see it as a non-binary mess. The CoC is an essay on a social contract that we aim to uphold. It codifies certain nuanced understandings of the world and demands people to grow those understandings. That is a certain kind of politics. And that is exactly how the world works. It is a constant negotiation of politics. There’s no clear way to categorize what it is. It is a mess.

    The rules are rules. The rules aren’t rules. The rules apply to everyone equally. The rules don’t apply to everyone. The rules are clear. The rules are ambiguous. The rules ought to be respected. The rules can be changed. You can enforce the rules. You can’t enforce the rules. All of these things are true to various extent at various time in various contexts and situations. Everything is non-binary!

     So, does the CoC apply? It applies to the whole world!

  • How To Talk With People

    It was just yesterday that I read a book on behaviour change through positive reinforcement. Today I put aside all work and read another book: How to Talk with People: A Program for Preventing Troubles that come when People Talk Together by Irving J. Lee. It was recommended by Parth Sharma in response to my sharing Marshall Rosenberg’s video on nonviolent communication in my WhatsApp status with this note: “This is an old video on nonviolent communication. It’s been instrumental in my first steps towards using language carefully.”

    Language has always been a problem for me. More specifically, language used in interacting with people. That is, talking with people has been a problem for me. In my extended family I was the “adhikaprasangi” (a word that’s surprisingly common in Kannada and Malayalam — meaning “the quality of having too high an opinion of your own importance, and being too eager to tell people what to do”). In school I used to get into quarrels with teachers. In internet forums people have gotten so angry at me that I’m used to writing “I apologize profusely”. Even many of my close friends have sometimes felt I’m rude.

    There are people on twitter I know who proudly wear such attitude and continue to be assholes. But I’m in no way indebted to my past. And so, I keep looking for ways to improve the way I interact with people. The challenge, though, is that I don’t buy the “respect” argument. I consider it dishonest to use language to show fake respect. At the same time I have seen excellent videos like “The Art of Semantics” and the nonviolence communication one above which all talk about using language to move towards a better world. So the missing link for me was the logic that connects respectful expression with social justice.

    And that logic clicked in my head when observing people I care about disagreeing with each other on the wrong things. In some occasions I was also involved, in some I was passively observing. Either way, it has become a felt need for me — using language for productive communication and getting our acts together for social justice. On Monday, I had a conversation with Akshay who is part of a very well run organization and whose experience I trust and admire. He also convinced me that using the right words is worth it.

    And that’s where this book comes in. How to talk with people.

    About three-quarters of it had become clear to me through my own life experience even before reading this book. But a well-written book validating our experiences is immensely valuable to our learning. And in that way, this book is a must read. It also means I have one less book to write myself. I’m thankful for this book’s existence.

    The first chapter itself summarizes all the different problems we have in our conversations and what to do about them. It is a very great tl;dr for this book. But the whole book is around 134 pages and you can read it in one evening (at least with speed reading). I will quote from the first chapter to pique your interest.

    So as to indicate something of the scope and character of what is involved in this interest, the major findings and suggestions are here summarized.

    1. Misunderstanding results when one man assumes that another uses words just as he does. People are so eager to reply that they rarely do enough inquiring. They believe so surely (and wrongly) that words have meaning in themselves that they hardly ever wonder what the speaker means when he uses them.

    Suggestion: Committee members need exercises in listening. They must learn not how to define terms but how to ask others what they are intending to say. Our advice: Don’t blame the speaker alone for the misunderstanding. The listener is involved, too. It takes two to make communication.

    2. Trouble comes when somebody contradicts somebody else without seeing what the first man was talking about. The speaker says, “You can’t trust the Abibs.” The listener says, “Yes, you can.” Then they go at it. When the Speaker was asked to specify, he told about Samo and Har and Myri. And, of course, they were untrustworthy. When the listener specified, he told about Mil and Janx and Car. And without a doubt they could be trusted. If the contradictor had asked first, the contradictee might not have had his feelings hurt.And the committee might have come to conclusions without that waste of time. The trouble mounts when nobody bothers about specifying. 

    Suggestion: Both leaders and members need to learn how to spot temperature-raising contradictions. They must ask, ever so politely: Are you differing on the details or on the conclusion? Does your generalization refer to what his does?

    […]

     

    And so on it goes till 14 points. Each one putting into words the troubles that we see around us all the time. It makes a fun read for those who are tired of the debates on twitter.

    The only disappointment I have with this book is that it assumes the presence of a leader to solve many of these issues. The frustration I have with all the groups I mentioned above are that there is no clear leadership structure. Perhaps this book thereby unearths a critical challenge that anarchist systems face. Perhaps my disappointment is for me to resolve.

    Nevertheless, the leadership traits that are written about in chapter XIV (On Preserving Human Warmth) was particularly useful. It talks about our own leadership styles. There is The Director (like a movie director), The Councilor (an egalitarian participant), The Parliamentarian (the one with the “the Rules of Order” at their elbow), The Quiet One (who is just there), The Good Host (who sets positive mood), and The Chief Clerk (who’s the guardian of the group’s virtue). It was quite fascinating to see various people I interact with and myself showing many of these traits in many meetings.

    The book is from 1952. The language of “man”, “him”, “his” is quite striking. At the same time, it is very interesting to note that many of the problems that we see today where exactly the same then as well. In a meta way, therefore, this book teaches more than what it talks about.

    A modern counterpart of this book might be Adam Grant’s Think Again. But unlike Think Again, HTTWP is focused more on the practical methods of the conversation than about the larger reasons behind it. It might be good to read this book after Think Again if you’re planning to read both.

  • Don’t Shoot Your Colleagues

    Over the course of my life a realization slowly dawned on me about feedback. Negative feedback rarely worked. And positive feedback worked magically!

    I started noticing this in myself first. I was learning rapidly and growing in environments where all I received was positive feedback. And wherever people were very cynical, I was just lost in thoughts and not growing.

    Then I took this observation seriously and did experiments. In JeevaRaksha trainings, for example, instead of giving the recommended “sandwich feedback” (in which you start with a positive feedback, then talk about something to be improved, and then wrap up with another praise) I switched to a “positive-only feedback” technique. And it worked well. People who were not very confident as trainers and made a lot of mistakes where becoming very confident and trying really hard and staying on as trainers. Over time they fixed their mistakes on their own.

    I have to admit that I was very hesitant to do this. I used to think I was “lying”. When other people did this to me I considered them “manipulative”. And I used to pride myself on being very balanced with my views — talking about positives and negatives — sometimes even balancing others’ positive views by talking more about negatives.

    And I still find it insincere when people are just praising an act in general without being specific on why they are praising it. “Great job”, “Great news”, “Fantastic” — all of this sounds insincere to me.

    And therefore I wasn’t sure about what this observation-experiment-result meant. That all changed today.

    I was watching videos of button pressing dogs and then a response video by KP, in which KP recommended this book called “Don’t Shoot the Dog”. That book confirmed everything I was vaguely thinking about feedback.

    It is written by Karen Pryor who used to train dolphins. The thing about dolphins is that it is really hard to punish dolphins. If you try to do anything, the dolphins will just swim away. So, to get dolphins to change their behaviour and do something that you want it to do, your only option is to give them fish. Reward. Positive feedback is all you have with dolphins.

    This, apparently, works very well for dolphins. And dogs. And cats. And all kinds of animals. Including humans. Including adult humans.

    In fact, the book makes no distinction between dogs and humans in its chapters. It gives you lessons on positive reinforcements, shaping, negative reinforcements, and a lot of theory on how to think about all this. Including on why this is not “manipulation”.

    I won’t spoil the whole book, but it basically says that positive reinforcements are much better than punishments. It forces you to switch away from the “traditional” training style of shouting at people or punishing them, and move to a style that actually works.

    The book was written much before “like” buttons were invented. But, if you read it carefully you can see that it explains much of how technology has been shaped to harness this kind of “manipulation” as well.

    If you are a “manager” of anything, or a parent, or a pet-owner, you should read this book. In general, if you want to change others’ behaviour, this is a must-read.

    It blends well with a theory of anarchic organizations which I’m developing. I think a theory on semantics which I want to start experimenting with will also connect. Those will be future posts.

  • Everyone is Everything (To Varying Degrees) – How Binaries Suck

    Yesterday in a journal club at SOCHARA, we were faced with many challenging classification questions.

    The paper we were discussing was titled “Metabolic non-communicable disease health report of India: the ICMR-INDIAB national cross-sectional study (ICMR-INDIAB-17)“. The second classification question was in the title. What is a “metabolic NCD”? Are there non-metabolic NCDs? The paper was only discussing diabetes and pre-diabetes, hypertension, obesity, and dyslipidaemia. What about things like stroke? MI? Cancer? Does the paper mean that these are not metabolic?

    My explanation was that the study started out as a diabetes study, but expanded to others, and, to fit the word restrictions that journal format puts out, they came up with a word called “metabolic NCD” to refer to the subset of NCDs that were studied.

    I searched on google scholar for any other reference to metabolic NCD and couldn’t find any other place where such a classification was being made. But on the WHO website, they classify the risk factors into two:

    Modifiable behaviours, such as tobacco use, unhealthy diets, physical inactivity, and the harmful use of alcohol, all increase the risk of dying from an NCD.

    Metabolic risk factors contribute to four key metabolic changes that increase the risk of NCDs: raised blood pressure; overweight/obesity; hyperglycemia (high blood glucose levels); and hyperlipidemia (high levels of fat in the blood). In terms of attributable deaths, the leading metabolic risk factor is elevated blood pressure, followed by raised blood glucose and overweight and obesity.

    This language is repeated in Table 2 of the paper too where it refers to the prevalences of diabetes, prediabetes, hypertension, etc as: “Weighted prevalence of cardiometabolic risk factors among the study population”

    What becomes clear is that categorizing NCDs into binary categories (like metabolic, not metabolic) is next to impossible. After all, nature doesn’t fit into neat categories. Every disease has metabolic risk factors. Every disease has behavioural risk factors. All things contribute to a disease to varying degrees. Rather than categorizing, it is better to think about how much the contribution of each is.

    The next discussion was on the BMI cut-off used. In Europeans, only BMI above 30 is considered obesity, with BMI between 25 and 30 considered only as “overweight”. But WHO Asia-Pacific region recommendation based on studies from China, Singapore, India, etc is that cutoff 25 and above should be “obesity” in India. Above 23 can be considered overweight.

    It was unclear why the cutoff of overweight could not have been used in this survey. At least, like “prediabetes” is quantified in the study, overweight could be quantified too such that we can anticipate an increase in obesity in the future.

    Similarly for abdominal obesity, waist circumference of 90 cm above for “males” and 80cm above for “females” were used.

    All these cut-offs are creating binary categories. The challenge with binary categories is that it does not account for the differences between people. By using different cut-offs you can account for some differences. (Like they account for race and sex above). But, those are not the only differences.

    (more…)

  • Ambedkar and Gandhi — They Couldn’t Have Been Friends

    For plenty of reasons, Ambedkar never considered Gandhi as “Mahatma”. And “naturally”, Gandhi rarely understood Ambedkar. In my experience of understanding how my privileges influence how I act, I believe that I’ve been able to appreciate where the difference between Ambedkar and Gandhi arise from. This is perhaps obvious to many scholars. But it was a shower-thought for me.

    Gandhi comes from privilege. Gandhi’s thoughts and ideas are all related to those privileges. That Gandhi chooses to wear lungi is because Gandhi wants to shun those privileges to be able to be able to feel right. I had/have the same thought process when it comes to clothing. I don’t like dressing up smart. Because I think from the privileged position of Gandhi. For me, losing my privilege is what gives me mental satisfaction. 

    When mfc was organizing the annual meeting on discrimination in healthcare, there was this debate on whether to put “Dr” prefix on people’s names. The philosophy that drives mfc is mostly Gandhian. They consider calling each other by first name and stripping titles as natural. I also think like this. I never put “Dr” next to my name. Shunning privileges.

    In another group, in Dalit History Month, there was a poster shared about an event related to remembering Ambedkar. It referred to Ambedkar as “B. R. Ambedkar” and not as “Dr. B. R. Ambedkar”. And some people rightly pointed out how stripping Ambedkar of the “Dr” title is a deliberate act. Ambedkar has to be referred to as “Dr”. And Ambedkar will always appear well dressed with a suit and a tie. These are revolutionary acts with immense meaning to Dalits.

    When there is no privilege to shun, what point is shunning privilege going to make?

    The same philosophy appears in a few other places too. At the mfc meet Anoop Kumar spoke about their life journey and gave incredible examples on how to change things for Dalits. Among the questions posed was a mediocre one as to what his thoughts on “Dalit Capitalism” were. Anoop brushed the question aside saying how not every battle can be fought at once and how Dalits should also get a chance to oppress now — obviously exposing the caste insensitive framing of the question.

    On the next day, the moderator of the concluding session, out of nowhere, made a comment saying how they disagreed with Anoop’s point. And Gandhi was quoted for assistance — “An eye for an eye will leave everyone blind.” Setting aside the fact that this was a misrepresented position being argued against, one can look critically at non-violence as Gandhi professed.

    Fasting, one of the most used “weapons” of Gandhi, makes no sense to people who are already starving. Imagine people being denied PDS through Aadhaar going on a fast unto death! They’re already starving to death. In non-violent methods, essentially, one can see people with privilege converting the every day violence faced by others into a method of protest.

    Non-violence also requires infinite tolerance of the status quo. If you’re frustrated with the way things are and lash out, that’s not Gandhian. If you are tired of the bullshit and call out the crap, you’re being violent. Again, the methods of patience are easier for those who aren’t mentally or physically affected by the problems.

    Ambedkar and Gandhi could never have been friends. Because Gandhi spoke the language of privilege. And Ambedkar spoke from the lived experience of oppression. If Gandhi would acknowledge privileges and own up the influence of those in the Gandhian methods, Ambedkar might have been okay to be friends. But Gandhi’s insensitivity towards caste would never make that possible. And neither would Ambedkar’s methods be okay for Gandhi. And that’s why they couldn’t have been friends. Because of Gandhi’s ignorance.

  • Repeated Names in NSQ Manufacturing

     There’s a 2014-2016 survey of drugs.

    That’s followed up with smaller surveys by CDSCO.

    We will compare with March 2023 report.

    Let’s look for repeated offenders.

    Skymap Pharmaceuticals Uttarakhand. In the old survey they had 14.04% samples NSQ. In March 2023, they’re NSQ again in 2 samples. (We do not know how many samples from Skymap were tested, so we cannot reproduce a percentage).

    There are two samples without manufacturer specified (of Ritonavir and Rivastigmine).

    There is Karnataka Antibiotics & Pharmaceuticals Limited coming up 4 times within the March list.

    Ridley Life Sciences Delhi shows up twice. They were in the 2014-16 list for 11/52 samples (21%) being NSQ.

    Neon Laboratories Maharashtra shows up once. They were in the 2014-16 list for 2/42 samples, that is 4% being NSQ.

    Preet Remedies Himachal shows up once. They were in the 2014-16 list for 2/47 that is 4% being NSQ.

    Shiva Biogenetic Himachal shows up once. They were in the 2014-16 list for 25/62 that is 40% samples being NSQ.

    Let’s take the October 2022 list to see if we can find more common names.

    Ridley is there once in this list too.

    Zee Laboratories of Himachal Pradesh makes one entry. Zee has an entry in the 2014-2016 list for having 40/222 (18%) samples NSQ.

    Mercury Laboratories Gujarat makes it to the list too with one entry. Mercury Gujarat was the topper in 2014-2016 list 

    Shiva Biogenetic Himachal Pradesh is back here too.

    Pure & Cure Healthcare Uttarakhand makes one entry. They were in the 2014-16 list with the misname Pure & Care for 3/38 samples (7.8%) NSQ.

     

    This is emerging to be a good tech project to track each pharma and their NSQ detections. Maybe for another day. 

    One challenge is that we do not know the denominator on the smaller surveys.

  • Engaging with the System – A Visit to IISc

    When Prasanna heard John and I were leaving Hari’s farewell party to join Ravi in the trip to Indian Institute of Science, PS let out a characteristic sigh and said “all the best”. It probably comes from experience of how incorrigible people in elite institutions are when it comes to thinking about broader determinants of health and communities.

    After all, I wasn’t wearing my usual grey short pants either. I had to dress for the “vibe” of the place. I was wearing a long pant and a full sleeve shirt. Even Ravi was wearing a shoe. And when we reached the place, we were welcomed by Dr H Paramesh who was wearing a suit. The only person who was under-dressed (relative to their usual) was Pruthvish who was at the venue too, but didn’t wear a suit today.

    Places and events like these have a way of making you uncomfortable in your skin. There’s a level of “sophistication” that’s expected in the way you carry yourself. Is it written down anywhere? No. It’s just the air. You won’t be able to breathe if you’re not walking and talking the way everyone around you is.

    Gender non-conforming people have stated how in public places, it is sometimes overwhelming for them when everyone is looking at them like “they don’t belong here”. Trans women feel unwelcome in healthcare clinics for similar reasons. 

    Perhaps what I feel is a bit like what they feel.

    Would you expect a trans woman to speak about “Health for All” at Indian Institute of Science? Or a garment factory worker? Or a manual scavenger?

    I wouldn’t. Because they would always be under-dressed. No matter how expensive their clothing is.

    It affects the content of the discussion too. There are certain “sophisticated” ways you would give a talk in a place like IISc. You can talk about things like “equity”. Even “gender equality” is fashionable. But words like “caste”, “transgender”, etc would not pass the vibe check.

    That’s the trouble I frequently have when “engaging with the system”. The system has certain methods. And certain taboos. It is often the taboos that are at the heart of the problem. 

    It is only if we talk about the terrible lived experience of the caste oppressed, or the gender minorities, or the poor that we can start to expose how unjustifiable the position of scientists in ivory towers are. When lived experience of discrimination and oppression and ill-health is put on the table, people will have only two options – either turn their faces away and ignore it, or accept how they are part of the problem. They can no longer sleep comfortably saying “we’re also doing our bit”. Because nobody is doing their bit as long as people are suffering.

    And those who are suffering will never be invited to talk to the system.

    The responsibility then falls up on those who are invited. To give a second hand account from their experience of the lived experience of suffering. To amplify the voices of the marginalized. To pass the recording, when they can’t pass the microphone.

    But that won’t pass the vibe check.

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