Blissful Life

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

Author: akshay

  • Lumbar Puncture and HIV

    Lumbar puncture is a fascinating procedure. It is cheap, it can be done in relatively remote places, and it can be learnt easily given access to enough people who need it.

    LP has an incredible role in the management of many complications related to HIV. I’ve heard stories about how there used to be 5 LPs done every day in VMH during the time when HIV was causing rampant destruction in Karnataka and India. When I was there, we would do about 5 in two weeks. Nevertheless, when a colleague asked on Twitter about CSF analysis, I thought I should write down some of the things I believe to know about Lumbar Puncture itself, especially in relation to its use in management of complications of HIV.

    The first many LPs I saw were all done for spinal anesthesia in KR Hospital. Till then all I knew about spinal anaesthesia was a friend’s description of the back ache he had post a “cool” hernia surgery because they had “poked many times for anaesthesia”. I think I hadn’t really thought about it till I was doing my anaesthesia rotation during internship. The first LP I did was also done during the same time – the “pop” and being in the space that you can learn only by doing. (If anyone thinks that all knowledge is codifiable like I do, here is what it feels like. Imagine there is a thick plastic layer laid around a piece of rusk. Imagine your needle piercing through the rusk and then splitting open the plastic layer. Now you are in the space.)

    The first time I saw an LP done for diagnostic reasons was in the medical emergency ward of KR Hospital where a young patient with some sort of neurological condition was being pinned down to the bed by 4 people and the postgraduate resident was dancing with the needle along with the squirming patient. Despite the grotesqueness of the picture, I found it incredible that 20-40 drops of a particular fluid can be so valuable in diagnosis.

    I learned the reasons when I was in VMH. There were many “spot” diagnoses we made using LP:

    1) Perceived high opening pressure in an HIV infected patient with neurologic symptoms – we send for cryptococcal antigen and it is almost certainly positive. (Always use Cryptococcal antigen test. Indian ink looks fancy under the microscope when it is positive, but is not as sensitive)

    2) High lymphocytes and proteins – you can keep your various tuberculosis diagnoses active. But even otherwise, you can’t rule out TB ever.

    3) RBCs and you can suspect sub-arachno… Just admit that you did a traumatic tap.

    But LP was mainly used for ruling out the infections. It is very simple to miss CNS infections in HIV infected patients. For example they will come with vomiting and you will examine their mouth and see oral (and possibly oesophageal) candidiasis written all over it. But rather unknown to you, they might also be having cryptococcal meningitis.

    It might be difficult to treat cryptococcal meningitis because Flucytosine is not something you find easily in India and therefore you are stuck with Fluconazole and Amphotericin B and good luck to you if you plan to give the latter in peripheral venous lines. (I’m not sure if the liposomal variety of Amphotericin B doesn’t cause as much phlebitis). But cryptococcal meningitis is a diagnosis you do not have to miss, if you are doing LP.

    It is a messy thing, but it is a life saving diagnosis. I’ve seen one patient die during the treatment, even though we were doing regular therapeutic lumbar punctures to reduce the intracranial pressure. But I’ve seen almost everyone else survive (including the case where I had to take PEP). I’ve also heard a very inspiring story from Dr Ramakrishna Prasad about a patient whom everyone else had given up on, coming back to life after switching over to the liposomal variety.

    A (thankfully) much rarer thing is HIV CSF escape syndrome. Hearing about this for the first time is when I realized which peak of the Dunning-Kruger effect I was on. You see, the blood brain barrier is a real thing. And not all of the HIV drugs cross this barrier the same way (paradoxic?). And therefore there are patients who can have no virus in their plasma, but if you do a CSF viral load test you will have a real surprise waiting.

    A not so uncommon thing which can be diagnosed through CSF is neurosyphilis. I always have to read the guidelines three times about when to use a VDRL test and how much to rely on it, but this is a test that we used to do as a protocol while doing an LP in HIV infected.

    Things like gadolinium enhanced MRI are becoming more useful than CSF analysis in diagnosis of things like tubercular meningitis. But from what Dr Rahul Abraham once told a group of us about his experience with MSF in Bihar, lumbar puncture will remain with us till the end of the HIV pandemic.

  • Annihilation of Caste

    Jat-Pat Todak Mandal probably wanted to be the #DalitLivesMatter of their time. That’s how they invited Ambedkar to their annual conference in 1936 to deliver a speech. Organization of conferences in that time and today have at least one thing in common – communication gaps. JPTM wanted Ambedkar to talk about abolition of caste. Like many social reformers, they wanted reforms that do not disturb the status quo. Ambedkar’s speech pointed out how caste is strongly intertwined with Hinduism. If one were to agree with Ambedkar, abolishing caste would require shaking the fundamentals of Hinduism. JPTM did not let Ambedkar know that they would rather not speak logic to the Hindu elite who attend their conference. At least, not when they sent the invitation.

    When the organizers saw the print of the speech to be delivered they straightened the record. Either Ambedkar can stay clear of criticizing Hinduism or they will find a way to cancel the speech. Ambedkar had by then printed a few hundred copies of the speech and was neither interested in changing the text nor in speaking at JPTM’s conference. The speech, thence, became the book. Annihilation of Caste.

     

    *  *  *

     

    Reading this book drastically changed the way I look at Indian independence movement and contemporary Indian politics. Very little of that was brought about by the content of Ambedkar’s speech. The speech is a rather predictable compilation of reasons why Hinduism flares up casteism. It is well written and logical. The points Ambedkar put forward can be directly used in debates even today. The politics around the book, though, is eye-opening.

    It is the same politics that made this book slip under my radar. It is why I have never asked the questions “Did Ambedkar really draft the Constitution?” or “What else did Ambedkar write?”. It is the politics of caste.

    Having grown up as an Indian elite, I did not (and do not) know well the politics of caste. To compensate for this elite ignorance, the book is now prefixed by Arundhati Roy’s essay “The Doctor and the Saint”. This essay is the red pill. If you take it you go down the rabbit hole of Indian politics.

    After that it won’t really matter whether you read the speech or not. Yet you will read it. Like you reached an oasis in a large desert you were thrown abruptly into.

  • How Can I Be Useful For You?

    I’ve been thinking about this for a long time. I haven’t still figured out how to execute this. But here’s the idea. I’m very privileged, purely by the accident of birth. There are millions of people less privileged than me in many ways. I think the right use of my privileges would be to help bridge the inequities in our society. And for that, I have to start somewhere. I’m doing various things, but I think I’m not doing all I can.

    Here’s the deal. I’ll list down a list of things that I think I can effectively help others in. I’ll also list down many of my privileges here. If you aren’t as privileged as I am in any one of these, you can feel free to reach out to me on any topic on the first list, and we can work out a way for you to take my time for your own benefit/growth/advantage.

    List of things I can work with you on

    1. Learning medicine, learning basic sciences.
    2. Learning programming, learning GNU/Linux system administration.
    3. Learning to use the internet.
    4. Contributing to free software projects.
    5. Writing essays/articles in English, learning English
    6. Conceptualizing research studies in health, academic writing, and publication.
    7. Public speech.

    I’m going to be a bit selfish and not list down everything that I can actually do for others. I’m sorry for that. But if you think there’s something related to the above but not exactly in the list, we can talk about it.

    List of my privileges you can use to compare

    By listing something down here, I don’t mean to imply that one is better than the other in any way. I just feel certain things have made things easier for me in my life, and I’ve listed those as privileges.

    1. Being male
    2. Being cisgender
    3. Being heterosexual
    4. Being born in a privileged caste
    5. Being born in an economically stable family
    6. Having my parents alive well into my adulthood
    7. Having young parents
    8. Being born to a doctor
    9. Being born to a teacher
    10. Being born to parents who are in government service
    11. Not having to support family
    12. Being the grandchild of three teachers
    13. Being born in a majority religion
    14. Having access to books from early childhood
    15. Having access to internet by 8th standard
    16. Having been to an English medium school
    17. Not having suffered psychological or physical trauma in childhood
    18. Not having physical disabilities
    19. Being tall
    20. Being fair skinned
    21. Having a lean body-nature
    22. Not having congenital or acquired illnesses that require medical care

    This is by no means a complete list. I haven’t added all the privileges that I accrued thanks to the above privileges. So have I not added the privileges that I am not aware of. Anyhow, if you think I am more privileged than you in any way, you should not hesitate to take this deal.

    You can find my contact details here.

     

     Post script: I have thought about how this can be considered virtue signalling. I am open to discuss ways of making this less about me and more about others. I’ve considered the idea of volunteering at NGOs. But I haven’t found a right fit at the moment. Neither is it feasible at the moment due to COVID. Also, I want to somehow be able to scale this idea and figuring out first hand what works and what doesn’t might be useful in that.

  • Why Wikipedia Is Evil

    Don’t get me wrong. I’m a fan of many things about Wikipedia. I have a small number of edits on Wikipedia too. But, I think democratizing knowledge creation is more important than Wikipedia. And that’s why the title.
    I have written with examples about how Wikipedia’s claims about it being “the sum of all human knowledge” is highly misplaced in my old article titled: “Don’t put all your eggs in one Wikipedia“. In that article I also talk about how Wikipedia could become the foundation for building a federated knowledge system. In this post I talk about why it is necessary to decentralize Wikipedia.
    Monopolies are bad
    It is not that there cannot be socially conscious and good natured monopolies. It is that the existence of monopolies in a society is bad. It stifles innovation by restricting it to only the monopoly. It gives great power to the people who control the monopoly. Arbitrary rules can be created by these people and everyone else is forced to follow suit.
    Healthy competition is the cornerstone of capitalism. Monopolies make competition tough. Worse, monopolies make competitors look bad even when they’re better. Monopolies make it look like the reason for the failure of competitors is incompetence whereas a large part of the reason could be the existence of a monopoly.
    Amazon, Uber, China, there are many examples.
    Monopolies don’t announce themselves
    That monopolies are bad is clear to many people. But recognizing monopolies is sometimes hard. A monopoly doesn’t always start out as a monopoly. And there usually isn’t an announcement when someone becomes a monopoly. In fact, monopolies always deny they have monopoly.
    Here is where Wikipedia becomes interesting.
    Wikipedia announces itself as wanting to compile the sum of all human knowledge (and sometimes even claims to be the sum of all human knowledge). I have ranted enough about this in the older post. But the fact that not enough people question this statement by Wikipedia founders and others should make us think: Have we accepted Wikipedia as the sum of all human knowledge?
    If we have, then we have laid the foundation for Wikipedia to become a monopoly. A monopoly over knowledge.
    We may be too late to act too.
    Wikipedia has prominent ranking on search results for many many terms. Often, people read only the Wikipedia result. These people linking back to Wikipedia creates a reinforcing feedback loop. (Of course, the role of Google’s monopoly over search and discovery of knowledge is also to be questioned).
    Because there is so much of knowledge already present in Wikipedia, many people think that what is not present on Wikipedia is not notable enough or is not important enough to know. Paid editing has existed on Wikipedia from a long time and the reason is that it is becoming increasingly impossible to build a brand without building it through Wikipedia also. And why is that so? Because a large number of people use Wikipedia to measure the relative relevance of knowledge. Wikipedia is becoming the trusted bank of knowledge. Wikipedia is gaining monopoly over knowledge.
    Not all of this is Wikipedia’s fault. There are many projects which try to become collaborative editing spots for various niche topics. Radiopaedia, for example tries to become a reference website for radiology. Yet, for many projects Wikipedia is a large competitor because it is the so-called “sum of all human knowledge”. Editors would rather write on Wikipedia than a smaller collaborative project.
    Because we give Wikipedia too much credit. We consider it the reference. We adore it. We are too scared to fork off. We make it a monopoly. Stop doing that.

  • Liberty vs Morality

    Liberty and morality can be seen as counter-balancing forces.
    Liberty applies to individuals.
    Morality is a social construct.
    Liberty is about what one can do.
    Morality is about what one cannot do.
    Liberty assumes each human is a rational being and respects them for that.
    Morality is enforced on humans by authority based on arbitrary consensus.
    Liberty allows a human being to achieve their maximum human potential.
    Morality can potentially prevent individuals from harming other individuals.
    Liberty and morality are not equally acting on everyone, though.
    Morality often sides with the more privileged. Because the authority to enforce morality rests with them too. In turn, liberty also accumulates with the privileged.
    Privilege may never get equally distributed. We must therefore constantly renegotiate the arbitrary rules of morality for the benefit of the less privileged.

  • Public Lives of Doctors?

    Social media has made our private life public. Facebook, Instagram, even WhatsApp (through stories) thrive on users generating engaging content. Often this content is snaps from daily life. A picture is worth a thousand words, yet can be generated in a second. Image centered social media platforms rely on this to keep themselves going.

    What about doctors (and other professionals) on social media? Is it any different for them? Should it be any different?

    This post has been triggered by the #MedBikini hashtag. Here’s one tweet that reveals what happened:

    This journal article considers social media posts where MDs hold alcohol, wear inappropriate attire, and give opinion on controversial social topics as “potentially unprofessional.” How would any of these adversely affect the care we give to patients? 😳 #MedBikini pic.twitter.com/G1iBuqtX8n

    — Ronnie Baticulon (@ronibats) July 24, 2020

    I will not spend a lot of time discussing this particular paper or the twitter response to it. But I will discuss sections from two of the references in this paper.

    A council set up by American Medical Association to address the subject of Professionalism in the Use of Social Media, included this paragraph in their report:

    Though there are some clear-cut lapses in professionalism that can and have been made online by physicians (such as violations of patient privacy or confidentiality, or photos of illegal drug use), there are many more situations that fall into a grey area.  Examples include photographs posted online of an inebriated physician, or sexually suggestive material, or the use of offensive language in a blog.  Any of these actions or behaviors would be considered inappropriate in the hospital, clinic, office, or other setting in which a physician is interacting with patients or other health care professionals in a professional manner.  However, whether physicians must maintain the same standards of conduct in how they present themselves outside the work environment is a more open question.  Physicians certainly have the right to have private lives and relationships in which they can express themselves freely, but they must also be mindful that their patients and the public see them first and foremost as professionals rather than private individuals and view physician conduct through the lens of their expectations about how an esteemed member of the community should behave.  Thus physicians must weigh the potential harms that may arise from presenting anything other than a professional presence on the Internet against the benefits of social interactions online.

    It is this particular paragraph that have been used when creating criteria for “potentially unprofessional” things in papers that followed. One of them has a section like this:

    Within the clearly unprofessional group, binge drinking, sexually suggestive photos, and Health Insurance Portability and Accountability Act violations were the most commonly found variables. Examples of binge drinking included pictures of residents lining up 5 pints of beer in front of 1 dinner plate, doing “keg stands,”and making comments about being drunk or hungover. Examples of sexually suggestive photos included simulated oral sex, female residents in bikinis with hands pointing to their breasts, and a female resident simulating intercourse with a large cannon. Profanity was also encountered, as was a link to a racist cartoon.

    Within the “potentially unprofessional” group, pictures of residents with alcoholic drinks in their hands were the most frequently encountered. There were also several polarizing political and religious comments made by residents, and 2 instances of residents holding a gun while hunting


    We get a better picture (pun intended) here of what these papers are trying to hint. With that in the background let me talk about a couple of things from my professional life that I’ve thought quite a bit about.

    Alcohol

    Alcohol is a controversial topic among doctors (because many doctors consume alcohol). I do not consume alcohol. I actively dissuade people from consuming alcohol. You could call me anti-alcohol. I have certainly been influenced by Dr Dharav Shah’s campaign against alcohol and his argument for why we should create a negative attitude towards alcohol (the way we have towards smoking) is convincing. And I consider it hypocritical for doctors to be consuming alcohol.

    There are plenty of doctors who disagree. Some of them are of the opinion that social drinking is not a problem at all. They want to draw a line between alcoholism and social drinking and want to allow social drinking without it progressing to alcohol dependence.

    There are some doctors who agree that alcohol is indeed dangerous, but do not agree with the idea that it is hypocritical for doctors to be consuming alcohol while asking their patients to abstain. This is a very important argument.

    One part of the argument is that what doctors, as professionals, give out as advice in a professional setting is not applicable to doctors themselves. That I can talk to my patient about the importance of not eating rice excessively while still eating two full biriyanis a day. That professionals need not hold themselves to the standard that they’re prescribing for their clients.

    The other part of the argument is that what doctors do in their private lives should not be dictated by their profession. Superficially it makes sense. But does it stand scrutiny?

    Firstly, does private life stay private? As we noted in the case of social media above, the notion of a private life that is wholly disconnected from public life is Utopian. What happens when something a doctor does in their private life becomes public?

    Secondly, would you apply that logic when what the doctor does in their private life is something that you find morally reprehensible? Say the doctor in their private life engages in adultery, directing pornography, or working for BJP’s IT cell (not that I find all of these morally reprehensible). Would you be comfortable saying “it is their private life?”

    This leads to the other thing that I am constantly thinking about.

    The impression that a doctor “should” make

    How should a doctor appear in front of their patients?

    The trouble starts from the first day of medical school. There is a certain way you’re expected to be dressing. There is a “smart” appearance dictated by the higher-ups in the hierarchy which usually included (for me) shaved face, short hair well combed, clean new aprons, polished shoes, and so on.

    It goes deeper. In “Be the Doctor Each Patient Needs“, Hans Duvefelt tells this:

    “Doctors are performers, not only when we perform procedures, but also when we deliver a diagnosis or some guidance.”


    The point Dr Duvefelt makes is about the therapeutic effect of a doctor-patient relationship. As a doctor, you need your patient to believe in you and in turn your advice. I talked about how this complicates everything about the doctor-patient relationship in my post about consultation fees.

    The gist of the matter is that doctors might have to do things (like shaving their naturally growing beard) to appeal to the completely irrational gut-sense of their patients. Weird argument, right? I don’t like it either.

    I don’t like it that I have to feign confidence in what I’m saying even when the field of medicine is not 100% sure about anything. I don’t like it that the biases that patients make up based on the impression I leave influence their adherence to the treatment regimen I prescribe. But these are how humans think and act.

    This is exactly why people dress well for an interview. Why politicians are careful about how they’re being photographed. Why celebrities have a link with fashion. And why people put their degrees on their Twitter and LinkedIn handle.

    I hate this world.

    Unprofessional

    Last day a patient messaged me. On SMS and on Telegram. My telegram bio includes pictures of me from a long time back and also a link to my telegram channel where I post links to my own blog posts. For some reason I responded to the patient on SMS although it was easier to talk on Telegram. I am not sure what to think about it. But at that moment I was not feeling comfortable with using Telegram to talk to a patient. The reason is that I blog mostly about technology. And multiple times in the past have people assumed I know very little medicine when they find out how much I know about technology. I don’t want my patients to read my blogs.

    That brings us back to professionalism. Professionalism is defined by society’s sense of morality. And that is where bikini pictures appear potentially unprofessional and sexually suggestive images appear clearly unprofessional to some. The #MedBikini hashtag is either about stating that private lives of doctors should not matter to patients or about the idea that bikinis are not immoral, or both.

    I think the entire post has been devoted to the point about whether we should worry about what patients think about us or not.

    The morality of underwear pictures is something that deserves a detailed debate. I end with the following question. Are sexually suggestive images unprofessional? Why?

  • The Connection Between Curiosity and Knowledge

    Last week, 7½ years after Aaron Swartz death, I was thinking about what made Aaron smart. There is this quote:

    “Be curious. Read widely. Try new things. What people call intelligence just boils down to curiosity.”

    Curiosity. It keeps popping up here and there.
    I was read Anand Philip‘s blog today. The “about” page is just three lines:

    Generalist.

    Superpower: Curiosity.

    Probably not a cat

    Can curiosity be a superpower?

    One of the answers was about The Oxford Electric Bell:
    There wasn’t much detail about the bell in the answer. Intuitively I was thinking it could be something like a clock that would require winding every now and then. But I wasn’t sure. So I went to the wikipedia page on it.
    That’s where I learned that it is an actual bell that rings about twice a second and holds “the Guinness World Record as “the world’s most durable battery [delivering] ceaseless tintinnabulation””
    Now there are many things to learn on this page. We might want to see the bell ringing on Youtube. We might want to read about perpetual motion. We might even want to read about the word tintinnabulation.
    Which reminded me of an old friend Akashnil Dutta who according to LinkedIn is now a Member of Technical Staff at OpenAI. It was about 9 years ago in a camp that I met Akashnil where he told me about magnetotactic bacteria. I asked him how he had come across this rather uncommon piece of information.
    He said he would use the “Random Article” feature of wikipedia to find new stuff.
    Curiosity is a super power.
    Read. Notice. Be curious. Question. Read more. Repeat.

  • What to Make of Itolizumab?

    It is the worst of times. Science is suffering an identity crisis. The world is in dire need of science. Science isn’t used to being rushed. “It is a giant and slow churn”, said a friend once, “and spews a breakthrough once in a while”. Is it possible to make the process faster? That’s what everyone is wondering. And praying. And waiting, eagerly. Science isn’t used to getting this attention.
    “Coronil is 100% effective”, said Patanjali folks. “Favipiravir is 88% effective”, said Glenmark folks. How to know the truth? Seeking truth has never been easy. Never has it been easy for journalists, scientists, or the common person. In some sciences there are multiple truths. Is medicine one of those sciences? Can there be a single truth in medicine?
    I won’t use words like epistemology and ontology in this post. (Because I still can’t remember which is which). But the question is essentially two:
    1. Is there a single truth?
    2. Is there a way to know the truth?
    I believe medicine is a dangerous subject because of these two questions. Biology is extremely contextual. A drug’s effect on a person with any particular infection can be influenced by a thousand factors including – that person’s biology, the day, where that person is, what that person is eating, what other medicines that person is taking, the virus that infected them, all the infections they’ve had in past, other diseases they currently have, the health of their body organs, and so on.
    When there are so many things that keep changing, how do we know whether a drug is going to be useful for a person or not? Most of medicine today is an approximation. Many drugs are used because when given to n random people it worked better than it not being given. A gross measurement, if you allow me to call it. Put something in a balance and see which side is hanging lower.
    Not that medicine is all guess work. He he. There are some theories. There are some “well-known” pathways. There are some molecules which we understand. There are some we don’t. There are some drugs we know act on some molecules in some of these pathways. Sometimes we don’t understand some parts of how a drug acts, but we fill in those gaps with the “random” trials as described above.
    For example, let us take Paracetamol which is a drug commonly prescribed for fever. And the only drug that many people need during COVID (and Dengue, and many other viral fevers). We don’t know how exactly it works. But we have a rough idea on the pathways that it affects. We also have very rich clinical experience in using the drug successfully for fever.
    The reason why we don’t rely a lot on theory in medicine is that we don’t have a lot of theoretical understanding about the biology of our body. We do know a lot. But there are still so many known unknowns. And who knows how much unknown unknowns.
    We know a bit about molecules called “interleukins”. We seem to know about a molecule we call Interleukin 6. It seems to have a role in acute immune responses. It may very well make sense to somehow block IL-6 to decrease the damage that could be caused by what is called a cytokine storm (which, as it sounds, is a storm that wrecks havoc inside the body) in sick COVID patients.
    We seem to know about a class of drugs called monoclonal antibodies. These are molecules (which can be natural or artificial) that target specific kind of molecules. There are some mAbs which seem to be able to target a type of cell called CD6 cells, including Itolizumab.
    Now, here is the deal. If Itolizumab can act on CD6 and decrease IL-6 and if IL-6 has a role to play in cytokine storm in COVID, then the inference could be drawn that Itolizumab can help sick COVID patients not die. That’s the theory.
    But the problem with medicine is that theory doesn’t always work. And sometimes what presents as reasonable with our current understanding of the body sometimes becomes dangerous when we actually try it.
    As for Itolizumab, Biocon seems to have given it to 20 patients with COVID and moderate to severe respiratory difficulty. And they all seem to have survived. Of the 10 they didn’t give it to, three people apparently died. I’m sure they’re doing this study on more people at the moment.
    According to them this is “statistically significant”. I don’t have a very deep understanding of statistics. Here, let me do the math.
    The way I read it is that based on that data we can be 95% sure that if someone with moderate to severe COVID-19 ARDS takes the drug their chance odds of survival is somewhere between 0.8802 fold to 415.9060 fold the chance odds of their survival without taking the drug.
    Didn’t I tell you this is the worst of times?
    Update: Don’t look at my math. That was not the point of this post. Also, my math sucks. Here is why:
    At a sample size of 30, the power of this study is like 30% which means it is completely unreliable. I think. I don’t know.
    Update 2: As per this article, and as per my understanding of beta, if p-value is already acceptable, then it doesn’t matter whether beta is high as all that power makes sure is that we don’t miss the effect when there is an effect.
    But then, am I confusing myself because in this study the effect of the drug is protective? I am 70% sure that the power of this study is not to be worried about.
    Update 3: Maybe the contradiction is resolved if we consider this as a type S error.

  • Moral Determinants of Health? How is it Different from Social Determinants of Health?

    There is a viewpoint in JAMA published under the title: “The Moral Determinants of Health” a couple of weeks ago.
    I went through it and don’t claim to understand it fully. But because there is a draft I’m working on about health as a fundamental human right, I think I understand what the author was meaning to say.
    Social Determinants of Health (SDH) are things like gender, race, caste, occupation, etc which directly influence someone’s health. According to WHO:
    The social determinants of health (SDH) are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.
    Where is the space for moral determinants when the definition of SDH includes a catch-all phrase “wider set of forces and systems shaping the conditions of daily life”?
    I think the space is at a meta level.
    Take race. Race, and racism are social determinants. But whether a society accepts racism and whether they want to change are moral determinants.
    What is a society’s moral stance towards the inequities within it? That is what moral determinants are.
    For example, when it comes to COVID-19 and lockdown/quarantine, the social determinants are things like job security, government policy on lockdown, migrant status, etc. The moral determinant is the collective moral maturity to take into account such SDHs when doing things. Whether the government feels the need to consider daily wage workers when declaring lockdown. Whether people feel the need to pay their maids even when they can’t come for work. Whether people consider it okay to isolate and discriminate against people infected with COVID. These are moral determinants.
    That’s why the author of the article mentions “right to health” multiple times. Right to health can be mistaken for a social determinant. It is a governance policy. A law. Something that can be included in the Constitution.
    But no. Right to health is not really a social determinant. Having the right to health holds no meaning. Right to health is a moral determinant. It is only when people understand “right to health” through the moral compass within and appreciate the meaning of what it means when someone has a right to health, that right to health becomes meaningful. That is when people will become ready to make the sacrifices required to ensure health for all. Sacrifices like giving up the luxuries of capitalism, paying higher taxes, waiting for one’s turn, and so on.
    The reason why my post on health as a fundamental right is still pending is the same. I couldn’t find a compelling reason to convey the moral argument behind right to health. It is dependent fully on whether people want to care for others or not. This is a fundamental moral argument. Should all people be equal? The proportion of people who justify inequalities in the society (either through economics, history, politics, or whatever) is the measure of how bad moral determinants of health are in that society.

  • Double Standards – Patanjali vs Glenmark; What is the Point of Ayurveda?

    A couple of days back Glenmark made a press release about Favipiravir which made it sound like they have a “game-changer” and “magic bullet” (according to various media houses). This was based on little evidence about its benefit. There is virtually nothing in public domain that shows that Favipiravir is useful in COVID. CDSCO explicitly approved Glenmark to do this.
    But today Patanjali is receiving flak and even has been officially asked by government not to advertise a drug they name “Coronil” which has very similar “research” to back it up. In fact, a quick look at the (?) methodology puts a placebo controlled trial by Patanjali at a better position to support the claim that their drug is useful.
    Such double standards of Indian people and government.
    Is this to do with Ayurveda?
    We have no issue with Ayurveda. We have elected a government which set up a ministry for Ayurveda. In fact, this ministry was one of the first to come up with “prophylactic measures” for COVID drawing on Ayurvedic and Homeopathic medicine.
    I personally believe Ayurveda is a science stuck in the ancient past. Thereby it is no longer science. But just because there are remedies mentioned in Ayurvedic textbooks, those do not become just Ayurvedic medicines. If those are tested with modern scientific methods, they are modern medicine too.
    If not for research into Ayurvedic medicine that helps improve modern medical field, what is the point of running 250+ Ayurvedic medical colleges in India?
    Is this to do with commercialization of Ayurveda?
    Patanjali (and other companies) has been in the business of selling Ayurveda products commercially for so long. Surely, commercialization of Ayurveda isn’t a crime.
    Is this to do with private interests during a public health crisis?
    Hasn’t every damn thing we’ve been seeing in the past 6 months or so been about that? Can you name one thing which has been selflessly done for public health? If you named something, I bet it involves an individual or a group of individuals caring for the people right around them. I mean, if you see people suffering right in front of you but you are developing a solution for some others, tell me that there is no private interest in there.
    Is this to do with scientific rigor?
    Where was the question of scientific rigor in approving Favipiravir? Is any data available for that? Was evidence taken into consideration? Was it considered whether the people who generated the evidence were also the people who were going to market the drug? Has there been a peer reviewed publication?
    What makes Coronil any different from Favipiravir? Is it that Patanjali’s claim is 100% while Glenmark’s is 88%? What if Patanjali claimed 99%? What is the right number for this game?
    Is it that anything that has a name that sounds Greek and Latin is inherently good?
    Like “hydroxycholoroquine”, “azithromycin”, “favipiravir”. Is it the name?
    Is it the fact that these drugs sound “modern”? What makes some chemicals modern and some chemicals ancient? Why can’t all chemicals be just “chemicals”?
    All these are rhetorical questions that lead us to the main part of this post.
    What is the point of Ayurveda?
    What are we doing with Ayurveda? What is the role of Ayurveda in today’s world? Can we modernize Ayurveda taking the good parts and plugging out weaknesses?
    Is there a way to re-imagine Ayurveda through modern scientific methods?
    Can we apply the same standards when looking at evidence in both Ayurveda and modern medicine?
    Have we extracted, examined, and integrated all the useful knowledge available in Ayurvedic textbooks into modern medical practice already? Is there perhaps a rudimentary theoretical framework in the way Ayurveda looks at wellness and illness? Can we build on that with the technological advancements that we now have to arrive at new theories on how to think about a human body?
    I mean, is there a central theory in modern medicine? Except at the molecular level where there is DNA->RNA->Protein, what kind of dogmas do we have in modern medicine? Isn’t there a need for such dogmas?
    I’m not saying Ayurveda has a correct theoretical framework. In fact, if you go down the slippery slope, you might say that I will say that homeopathy also has the potential to provide a theoretical framework. I’m not saying that. From my limited understanding of homeopathy and dilutions, homeopathy seems to have nothing in it.
    But Ayurveda is a different beast. Ayurveda was fairly useful during its time. It has sufficient nuance in its management algorithms to qualify for a thorough analysis. All I’m saying is, perhaps there is something to extract from it. And I’m saying this from my limited experience interacting with Ayurveda practitioners.
    Nevertheless, why double standards?
    Why do we trust “modern” medical “research” by default and distrust Ayurvedic “research” by default?
    I mean, what does it tell you that a country which has no issue in pharmacies selling Ayurvedic medicine for every other condition says foul when an “innovation” is attempted for dealing with a pandemic that nobody has a clue how to handle?
    When will we stop lying to ourselves?