Blissful Life

Category: mbbshacker.blogspot.com

  • The Overcompensating Sociologists of Public Health

    Reflexivity. That’s a word very dear to sociologists. It just means how we look at the world is influenced by who we are. But like many things sociology, you give it a word and then you make a big deal out of it.

    So much that some of the sociologists reading this post are already raising their hand saying “Hey, but you’re talking about ‘positionality’. Reflexivity is actually about how we take into consideration our positionality in our research”.

    Shouldn’t the fact that how we look at the world is influenced by who we are automatically also mean that we should be cognizant of that and take that into consideration in our research? Apparently sociologists can’t do that automatically without having a different word for it.

    Or maybe they can and I’m just stereotyping them. After all, my identities put me in the positionality of an anti-academic-sociologist.

    This post is not about sociologists who don’t care about the world. And therefore I am not going to write about how there are some of them who just keep doing esoteric debates funded by public money in public universities.

    This post is not about the superficiality of academia. And therefore I am not going to write about the publication game.

    This post is about the sociologists who overcompensate for their identities.

    It starts with privilege. By their very nature, there are a lot of people in academics and sociology who come from very privileged backgrounds. For some of them, academics might have led to their understanding of their own privileges. This can probably explain why they keep going back to jargon to describe the plight of the world, because it appears that without the words given to them by academics they find it hard to understand or describe the wrongs in the world.

    My conjecture is that when they look at a subject like traditional medicine in the context of pluralist health system in India, they go “Oh, I’m from a privileged background and therefore I should compensate for my biases against traditional medicine. I shouldn’t be part of the ‘undemocratic’, ‘elitist’, and ‘self-centered’ biomedical field of this country, I should rather side with the ‘downtrodden‘” because I cannot imagine any other reason for one to claim that traditional medicine being sidelined as “unscientific” is because of the “political economy of knowledge production” and that scientific community has to devise ways to legitimize traditional medicine.

    Modern medicine has several problems. The practice of modern medicine is riddled with problems too. Knowledge production in modern medicine has a definite politics. But to use these as arguments to promote traditional medicine is a sophisticated form of whataboutery. And some of these academicians do this as well so as to talk about traditional medicine.

    I call these people “the overcompensating sociologists of public health”. Their “solidarity with the oppressed” is more about their own struggles than about the struggles of the people. They would rather stick to their arguments romanticizing traditional medicine (getting applause from the cult of anti-science orientalists) and have people die eating roots and leaves than have their praxis in the form of advocating for better access to quality healthcare.

  • Does Medicine Need a Paradigm Shift?

    Let’s start with physics

    As my brother’s T-shirt says “The Pulse of the Earth is in Physics”. Physics is a fundamental science. Also called “pure” science. That is a fancy way of saying it is reductionist. When you think of an apple falling to Earth in physics, all you think about is its mass and the forces acting on it. Everything else is immaterial to physics, including the questions like “Is the apple rotten/ripe?”, “What is the probability of the apple falling on a rabbit and killing it?”, “Are there hungry people waiting for the apple who won’t get to eat it?”, and “Is the apple cursed?”

    The question whether apple is rotten can be answered by another branch of science called biology. Physics and biology are called natural sciences. These are branches of science which rely on observation of the universe to reach at inferences on how the universe works.

    The question on probability would fall under mathematics. Mathematics is a bit different from natural sciences. Because it is based on axioms and logic. Such sciences are called formal sciences.

    A hungry class of human beings not getting to eat apples and the reasons behind it would be the matter of study in social sciences.

    The cursed apple is a subject of religion and superstition. These are, by definition, not questions for science to answer.

    What kind of science is medicine?

    Medicine is not a pure science like physics. It is an inter-disciplinary, applied science. Medicine uses several branches of science like biology, chemistry, and mathematics in its own goals.

    A medical practitioner has to know several sciences like anatomy, physiology, biochemistry, pharmacology, and microbiology to be able to practice medicine well. They would also need skills in probability, reasoning, and logic. Also critical are skills like communication, empathy, leadership, and management.

    There are also several other forces in play that influence the practice of medicine – education, medical training, health systems, politics, economics, religion, human resource, war, and so on.

    The question of a paradigm shift in medicine is thus complicated. Which part of medicine would the paradigm have to shift in? In the numerous sciences that make it up? In the way it is practiced? In the way people are trained in it? In the way the systems around it are organized?

    Science is the only way of knowing 

    What is science? 

    The opening statement from Wikipedia is: “Science is a systematic endeavor that builds and organizes knowledge in the form of testable explanations and predictions about the universe.”

    Science is what allows human beings to operate in the world. It is the sum total of all that we know about the universe through thousands of years of living in it and observing it. It is the reason why we know that if I strike a lighter in a particular way with a knob turned on the gas from a cylinder will come into the stove and start a fire. It is how we cook and eat. It is the reason why we know that elephants can lug trees while cats or dogs can’t. It is the reason why we are able to talk to each other over the internet.

    Everything we know about the world is through theories and observations that confirm those theories. When we come across observations that contradict those theories, we are forced to come up with better theories. But till then, we seem to be able to live on earth with the old theories.

    Is there any other way of knowing about the world? Think about it. Everything that you know about the world would come from your own observations and theories, or those by others that you have read about. There is simply no other way to know facts about the world.

    You might say, “Oh, to know whether it is raining, I just have to look out of the window. No science involved”. But hey, what you’re doing is observation. And then forming a theory that it is raining. What if there is a film shoot going on and they’re pouring water with a hose and that is what you’re observing through the window?

    The whole experience of seeing water drops falling down from sky and knowing that “it is raining” is based on science. It is based on human observation since time immemorial of the natural phenomenon called rain. Even when you’re looking out of the window to say whether it is raining, you’re using science. And it is science that allows you to say whether it is actually raining or a film crew pouring water.

    You might also say, “Hey, I know cycling, is that science now?”

    When you say you “know” cycling, the knowing refers to a particular sense of muscle memory that you have developed through practice. But this is not the kind of knowing we are talking about. We are talking about knowing how the universe and everything in it works.

    Read a related post about this question of whether science is the only way of knowing, where I argue that if there is a way to know, then science is the only way of knowing. Consequently, there are some things we cannot know, and this question would not apply at all.

    Queering science

    While indeed science can be seen purely as methods of rationality as above, it is has to be acknowledged that science is ultimately a human endeavor and thereby it reflects all the faults of the human society almost as it is.

    I’ve dealt with this human aspect of science in an earlier blog post and so I won’t repeat those points here. Suffice to say, there is an intersectional approach to the practice of science that’s missing in mainstream science.

    What about applied sciences?

    When it comes to an applied science like medicine, the problems seem to compound. Many of the sciences that make up medicine are all super hard to study. The tools we have are limited. And the institutions that we have are very problematic spaces (in terms of patriarchy, violence, oppression, and discrimination).

    When faced with such a complex challenge, many people prefer to run away and find comfort in places that nobody is finding faults with (although they would be riddled with even more issues). That’s why many people turn to Reiki, Homeopathy, Ayurveda, and so on. This gives them psychological comfort. But this is no solution to anyone’s problems. We will talk about that later.

    Applied sciences deal with the real world. One that is filled with uncertainties. One where perfect knowledge is impossible, but action is inevitable. It takes a lot of interdisciplinary thinking to operate in the field of applied sciences.

    Let us look at what some people call Evidence Based Medicine. EBM is misunderstood by many. They give undue stress to the word “evidence” and think that a randomized control trial is the be-all and end-all of EBM. These are the people who assume that medicine is based on a paradigm of large numbers. What they do not know is that there are three pillars of evidence based medicine:

    • Clinical judgement
    • Relevant scientific evidence
    • Patients’ values and preferences

    Clinical judgement is where the practitioner comes in. The validity of medicine rests on the practitioner making the right observations and judgements about a particular situation. Similarly, we need a body of evidence, a body of science before us to be able to make any intelligent observations. And considering all of this is about a patient, it is imperative to keep their preferences in the whole matrix of evaluating what to be done.

    Let us talk about relevant scientific evidence a bit more because that seems to cause a lot of confusions in the world. (Even in an otherwise brilliant talk about integrated medicine, Ravi Narayan equates medicine to controlled clinical trials, for example. (19:30 in the video)).

    It is all about knowing the truth, as we discussed in the beginning. How do we know what to do in a particular situation. When someone comes in front of you with cough, weight loss, and fever, what do you do? What if you also found in the sputum of this person the organism that is known as Mycobacterium tuberculosis? What do you do? How do you know what to do? That’s the important question.

    If you knew magic, you could perhaps try that. You could get rid of all the M. tb from their body magically! That would help them. You might save them from certain death.

    But if you didn’t have the evidence built over centuries of human beings struggling with this disease called tuberculosis, how would you even know that this person would die soon?

    It is only the scientific method of knowing the universe that can guide us to move even an inch forward towards helping those who are struggling.

    The alternative to science

    The alternative to science is the pandemonium of opinions and beliefs. There are people who consider these as ways of knowing the universe. But they don’t critically think about their own philosophy.

    Firstly, whose opinion counts? Who is authorized to make opinions? Is it reserved for people who meditate in the Himalayas? Can you and I do it? Does it have to be done high on weed? How do we measure whether someone is legitimate in claiming that the shit they pulled out of their ass is the correct knowledge about the world?

    Secondly, when you have two people claiming two shits that are contradictory to each other, what do you do? Let’s say person A says eat leaf A, while person B says eat leaf B when confronted with the patient we saw above. Which leaf should the person eat? Both leaves? No leaf?

    The only way to evaluate anything and arrive at an actionable prediction about the universe is through science. If you look at what’s typically called pseudoscience, things like Homeopathy, what you can see is that underlying all these are certain theories that are of very low quality. These theories are sometimes not verifiable. And if at all they’re verifiable, they end up to be false. Proponents of these pseudosciences typically take comfort in the space where they come up with a theory, believe in that theory, and don’t bother verifying those in the real world.

    Paradigm shift in medicine?

    Having said all that, let us come to the question of the need for a paradigm shift in medicine.

    It is easy to speak in vague terms about “holistic” approaches that incorporate a paradigm of being “more rigorously attentive to the individual while keeping in view the larger picture”. But when it comes to practice, we can quickly see how rhetoric like these are hollow.

    Does attentive to the individual mean using genetics and personalized/precision medicine? Does it mean just taking patient preferences into consideration? How scientific and rigorous do you have to be when you say “rigorously attentive”? If a person says “I think homeopathy will work for me” and you diagnose tuberculosis in them, what do you do?

    What about the other question. How many people practicing modern medicine are actually practicing evidence based medicine? How many do rely on science and evidence to manage their patients? How many randomized control trials did people use to prescribe drugs during COVID. How many RCTs are followed when people prescribe platelets and antibiotics for dengue? How many RCTs are followed when people diagnose typhoid with a single Widal test of 1:40?

    Does the “larger picture” include social, political and economic determinants of health? But does it also mean that the focus should only be on distal determinants? Would you not worry about Anti-Tuberculosis Therapy in someone with TB or will you only keep saying “nutrition!”, “nutrition!”, “nutrition!”. Fine, nutrition. But how? Will you feed this person out of your pocket or will you keep saying the government should come with food security schemes? Fine, the government should come with food security schemes. But will you work with policy makers on making such schemes a reality or will you keep writing about it?

    Yes, a paradigm shift is necessary. A paradigm shift that puts people first. A paradigm where sacrificing rationality for practicality and/or sacrificing science for pluralism doesn’t kill innocent people. A paradigm where working on social determinants goes hand in hand with treating now those who are suffering now. A paradigm where paternalism and saviour complex are replaced with solidarity and praxis. Nobody can say no to that paradigm shift.

    ***

    Footnote: There’s a human tendency to come up with alternative hypotheses to explain seemingly miraculous phenomenons. When I was 16 years old, I came up with “ASD rays” to explain telepathy. Thankfully there was a group of people who explained to me that my theory, however “sound” explains a phenomenon that’s non-existent. At that point in time James Randi offered a million dollars to anyone who can demonstrate paranormal claims. And nobody won it, of course.

    As long as people think that things like homeopathy actually are more than just placebo, they’ll come up with theories that go into sub-atomic realms to explain how these work. That’s natural. And they’ll keep struggling to understand why rational people reject their theories. If you are empathetic to them, you’ll realize that to them it is inevitable that these theories must be true because otherwise how do they explain to themselves their “miraculous cure” that others believe is charlatanry?

  • By Doing “Government’s Work”, Are We Making It Easier for The Government and Worse for the People?

    At the end of the CHLP session today Akshay (not me) asked something like: “When we do work that the government should be doing, are we making it easier for the government in some ways, and also making it more difficult to hold the government accountable?”

    This is a question that only someone who is truly invested in community work can ask. They are worried that the government is going to invest less in that particular problem, that in the long run it becomes harder and complicated because of the reliance on “bespoke” solutions. (The example given was how government relies on the voluntary effort of data by covid19india.org / covid19bharat.org to get COVID related counts and how there is no other system to track these counts)

    I do not claim enough experience to answer this question.

    But if we break down this question, the concerns we have are:

    1. How sustainable are such bespoke solutions? If we could keep doing it forever, then why should we not do it forever? Should government ever take over?
    2. Are such bespoke solutions less effective than more universal solutions? If yes, are we causing a less than optimal outcome? If no, are we preventing a scale-up of these solutions by the mere fact that it came from outside the government?
    3. Does access to and/or existence of such bespoke solutions make it difficult to demand more universal solutions from the government? (Either by making people reticent or by making the demand look less urgent)

    A few counter points are:

    1. But how long should I wait for the government to do the right thing?
    2. Who is at the receiving end of our desire to wait for a universal solution? Who suffers when we wait?
    3. Let’s say I don’t attempt the bespoke solution. What do I do now? Should I now force the government to build a solution?

    The way I avoid these questions are by thinking:

    • The government is a huge, inefficient, highly hierarchical organization with not much capability to build innovative solutions. Therefore, expecting government to come up with a good solution is pointless.
    • I should do things that give me joy, not what brings joy to the world. If bringing joy to the world in certain ways brings me joy, then so be it.
    • The second-order, third-order effects of our actions are very very hard to predict. No matter how much we “calculate”, not much is going to come out of the calculations. We have no way to say that any particular action is what is going to help the world. We just do what we want to do and hope that it turns out to be a good thing. Often, there is no way to actually say whether something turned out to be good either.
    • If we are creating value, putting value out into the world, it is more likely than not that we’re doing something right. The value will compound in ways we cannot anticipate. Always.

     If you are reading this and you have answers to some of these (existential, sorta) questions, let me know.

    Update

    I sent this to Tanya and Prashanth. Prashanth tried to add a comment and failed. That comment is:

    “This is an important question to “struggle” with especially for those
    (like me) who are involved in such “solutions” that are often not only
    outside-the-box, but also as rightly pointed out, being designed outside
    the “public” system. For an individual like me for whom, working with
    indiviudals/communities/populations is coming from an ethical
    imperative and from wishing to move our society towards health equity,
    there is – I confess – no other way. What do we who do not wish to work
    within governments for various reasons do? I think what we can do is
    build coalitions, networks and allies which nudge/push/critically
    demonstrate the need for public services and systems to do more. And for
    me, such efforts are ways of showing that more can be done. Another
    reason to do this is to address the inertia that sometimes develops at
    middle level institutions (like districts) where the glamour of
    word/jargon based policy vocabulary is not there and the fatigue of
    under-resourcedness is a daily reality. So, I believe such efforts can
    hopefully spur creative thinking within public systems, build allies
    within the system and who knows…knowing the complexity and unintended
    effects these things have…some things stick…some things
    flourish…improve? But, certainly there ought not to be a claim that
    such accomplishments (if they are such) will automatically result in
    “systems change”….these are some of my thoughts. “

     

    Prashanth also got Werner Soors involved. You can read W’s comment below this post. To me, W has more or less arrived at the crux of the dilemma. The struggle is related to the dichotomy created by the ideal government and the real government. But as W points out, it maybe worth trying to become part of the government through becoming part of the people.

    Coincidentally, I saw this video by The Ugly Indian today

  • What Can An MBBS Doctor Do?

    In the protest surrounding suspension of Dr Saibal Jana and Dr Dipankar Sengupta, a debate has emerged around what an MBBS doctor can and cannot do, especially in rural settings. This is a very complex question that requires a complex legal answer.

    There are several relevant case laws and even acts like Clinical Establishments Act which talk about some aspects of this debate. But let us look at it from a more fundamental and fresh perspective.

    Law is not static. It is subject to continuous change. Law is not blind either. It is acutely aware of context. Therefore, there is no need to frame a universal, absolute, strict law regarding a nuanced question like this.

    What are some of the considerations that must be kept in mind when framing a law on this question?

    – How to bring equitable healthcare to the people of our country?
    – How to protect people from harm?
    – What is the situation with respect to human resource availability in rural healthcare?
    – How do referral pathways work in our country?
    – How does medical education work?

    What makes a rural place “rural”? Places are considered rural when they have small population and consequently very few markers of urbanization (like large buildings that accommodate many people in a small area and huge roads that accommodate heavy traffic). Many rural areas won’t have a movie theater. Because there are so few people that it would be difficult to run a cinema and make profit. Similarly, the economics of small numbers do not allow a “specialist” doctor to practice only their specialty in rural area. It also makes it difficult for them to invest in equipment that might be required for specialty practice. In many ways, specialist practice is economically impossible in rural areas.

    On the other hand, a generalist is able to successfully practice in rural areas. Someone who is willing to see a large number of people with many different health conditions can survive in a rural economy rather comfortably.

    Is it possible to have multi-specialty hospitals in rural areas, if the rural economy cannot sustain specialists? Yes! This is possible through team work. There are many rural hospitals which work by association with specialists who might be present only on one day a week or available over phone calls. This unique symbiotic arrangement has organically developed in many rural places in India. The reason is that just because a place is small, the health needs of the people in that place will not be small. (To paraphrase Dr Yogesh Jain). Rural places also require specialized care. The demand is there, but the volume is low.

    If you can have one specialist come on one day and manage all the cases that require that specialist’s care, the rural hospital can club many patients together on that particular day and make it an economically feasible day for the specialist. If the specialty is something like surgery which requires post-op care and follow-up, rural hospitals can manage with generalists who work with the guidance of specialist in arranging that follow-up care.

    What specialists typically tend to do in such arrangements is also empower the rural generalist in being able to handle more complicated cases. This happens in many ways. The availability of specialist guidance increases the confidence of the generalist. Doing things with a specialist transfers necessary skill. And working under these arrangements for a while makes them able to work independently as well.

    That is how medicine is. Medicine is not something that you finish learning in a specific number of years in a medical college and then go out and practice forever. Medicine is something that you learn every day. Even the specialists learns on the go. They hone their skills day by day, with every new patient.

    Now, let us imagine the same rural area without this delicate arrangement in place. Imagine a doctor who has just finished MBBS has come to practice in a rural area and have started a small clinic or are in a PHC. What are they supposed to do there? Can they treat pneumonia? Can they manage someone with schizophrenia? What about deliveries? Can they conduct a delivery? How about I&D for abscesses? Can they prescribe Morphine for palliative care? Would it be alright for them to stabilize a poly-trauma patient? Someone with an Acute Coronary Syndrome? What happens when a patient comes to them with long history of cough and fever? What about someone with chronic headache? How about someone with loss of balance? Or someone with a distal radius fracture?

    In a world focused on specialties and urban model of care, many of these patients would have to be referred to the average specialist in the nearest urban setting. But there is not a lot of insight into how many of these referrals are successful. How many reach the right kind of “specialist”? How many decide to suffer than seek inaccessible care? How many settle with an alternative medicine practitioner who decides to take the risk of handling the condition with the knowledge and confidence they have? How many die lost in the referral pathways? How many die at home?

    In a world that’s person-centered, we would encourage the MBBS doctor to take all of these factors into consideration and take a calculated risk in cases where that would be in the best interest of the patient. In cases where the patient is otherwise going to not receive any care, it is often in the best interest of the patient that the MBBS doctor, even if they do not have the skill of an average specialist, attempt something risky. 

    Of course that shouldn’t come at a cost to the patient. This has to be a careful decision that’s discussed with the patient. A shared decision has to be made between the doctor and the patient as to the risks and the alternative options. But it is these informed risk taking that’s going to help that doctor level up. 

    A progressive outlook at medical education should think about what resources can be made available to this isolated doctor to be safe in the risks that they’re taking. What kind of guidance and resources can be made available to them to increase their chances of success and increase their level of competencies. 

    It is when we are able to create such empowered generalists in rural healthcare that we can start bridging some of the huge gaps in rural healthcare. The law should not become an obstacle in this mission. The law should be progressive enough to encourage these possibilities. The law should be promoting this decentralization of healthcare. The law should be focused on people and their well-being.

    The question should not be “What can an MBBS doctor do?”. The question should be “What should an MBBS doctor do?”

  • Essential Digital Literacy for Community Health Folks: Part 1

    Whether one likes it or not, everything is getting digitized. And it is often a good idea for human beings to keep abreast of changes. This is a series of posts designed with community health folks in mind to help them develop mental models around the technologies that make up the digital world.

    In this post, we will look at certain foundational terms like “information”, “data”, “communication”, and “computer”. Then we will connect it to words like “internet”, “server”, and “cloud”.

    ***

    Information / Content / Data

    Anything that is meaningful is “information”. Emails, videos, textbooks, numbers, anything that you can imagine and represent or store in some form.

    “Content” is just another word for information used in specific contexts. Like if I’m sending you an email, the body of that email would be called “content”. An article has content. A youtube video has content. An instagram post has content. A tweet thread has content.

    “Data” is yet another way of looking at information. If you collect information about 50 people while doing a research project and put it in a spreadsheet, you might call it research data. If a hospital keeps a medical record of a patient who was admitted there, that would be called health data. If you write a brief bio of yourself and share it with someone, it might be called a biodata. 

    ***

    Communication

    Human beings have been communicating forever. We can talk to each other. Or we can draw something on the wall which someone else can come back and read later – perhaps after a day, perhaps after centuries. We can write letters. We can write emails. We can message people.

    Communication is just transfer of information/data from one place to another, from one mind to another.

    It need not always be one-to-one. It can be one-to-many. Mass communication.

    We will come back to the term ‘communication’ in a while.

    ***

    Computer / Computing device 

    A computer is a machine or a device which can be used to view, store, transmit, receive, and manipulate/transform data or information.

    Is a physical book a computer? It can be used to view, store, transmit and receive information. But it cannot manipulate or transform that information.

    What about a calculator? Is it a computer? A calculator can be used to view, store and manipulate/transform information. But it can’t really transmit or receive information, can it?

    What about a smartphone? You can send and receive data/information via smartphone. You can store it and view it. You can also manipulate and transform it. A smartphone is a computer.

    So is a laptop, or a desktop.

    Computer as a Communication Technology

    You might have noticed that in the above section, I am referring to the computer as a machine that can be used in receiving/transmitting information, or, communication. In the past people might have called a calculator a computer. But today, computers are almost universally able to communicate and therefore it is ideal to view computers as machines useful in communication technology.

    What kind of communications do computers allow?

    Email, WhatsApp, YouTube, Instagram, Twitter, research publication, reading journals, reading news, writing blogs, reading blogs, putting things on a website, viewing a website, so on.

    (Remember – your smartphone is also a computer!)

    ***

    Internet

    The Internet is the simplest and most powerful creation of human beings in the past few decades.

    It is super simple. Imagine I (A) connect my computer and your (B) computer with a cable that can transmit information. Now I can send messages from my computer to yours and vice versa. A—B

    Imagine now that you connect your computer with that of another friend (C). Now, I can send a message to C through your computer.  A—>B—>C

    If D connects to C’s computer, D can send a message to me. D—>C—>B—>A

    Imagine most of the computers in the world connected to each other through each other. Like a huge “net”. That’s internet.

    This connection need not be through a physical cable.

    It can also be through the electromagnetic spectrum. 4G, 5G, WiFi.

    You might have a question here. You have only one computer in your place, and it is not connected to any other computer. How are you able to browse the internet, then?

    Well, actually, when you’re connected to internet (be it through wifi, be it  through mobile data), what you’re actually connecting to is a computer. That computer would be in the office of your internet service provider (Airtel, BSNL, Jio, etc). And they connect their computer to the rest of the world through massive underground cables.

    Basically, the whole world is connected through cables and electromagnetic spectrum. And that’s how internet works.

    ***

    Server

    A computer is not a magical device.

    If your computer is switched off, you cannot read your emails from it.

    If your computer is not connected to the internet, it cannot send or receive information from the internet. If your wifi is switched off, or your data pack is over, you cannot receive whatsapp messages or emails.

    But if that’s the case, what will happen to the WhatsApp messages others send to you when your phone is switched off? Where does it exist? Where is it stored? 

    Let’s say B’s phone is switched off. A sends a WhatsApp message to B. A then switches their phone off. Both phones are now switched off. Does the message exist anywhere?

    B switches their phone on now. (A’s phone is still switched off). Will B receive the WhatsApp message sent by A?

    The answer is yes. And the answer is “servers”.

    A server is just a computer that is kept on and connected to internet all the time.

    When A sends a WhatsApp message to B, A’s message is not directly send from A’s phone to B’s phone. Instead, A’s message is send from A’s phone to a computer owned by the WhatsApp company. This computer is always kept on. This computer might physically be located in California, or London, or Mumbai. We do not know for sure. But WhatsApp knows. And “server” is just another word for this computer that is always on.

    This server sends the message then to B whenever possible. If B is online, it will immediately send that message. If B is switched off and later comes back online, the server will send the message to B then.

    That’s what a server is. A computer that’s always online.

    It is not just WhatsApp. Almost everything in today’s internet works through servers. If you’re reading this through an email, you are probably getting that email off your email providers’ server (Gmail/Yahoo/whoever). If you’re seeing this on a blog, you connected to Blogger company’s server to download this post to your computer.

    ***

    Cloud / Cloud server

    Cloud is just a fancy name for servers run by big companies like Amazon/Google/Microsoft. When I run a computer at my home and keep it always online, it is called just a “server”. But when a capitalist company runs a computer at their air-conditioned, high security, custom built buildings, it is called a “cloud server”, or sometimes simply “cloud”.

     ***

    We will look at some related words like “client”, “database”, “website”, “protocol”, etc in the next post.

  • Analysis of v-safe response data

     Amar Jesani shared in mfc group link to an article about v-safe data release.

    The actual data could be downloaded from this website called icandecide.

    The 5GB file can be extracted with p7zip to a 25GB CSV file.

    $ md5sum consolidated_health_checkin.zip
    53ff7a8153f44eaab4166f722b726fe1  consolidated_health_checkin.zip
    $ md5sum consolidated_health_checkin.csv
    345cf6ca148832141260aab8638bf0dc  consolidated_health_checkin.csv

    $ wc -l consolidated_health_checkin.csv
    144856044 consolidated_health_checkin.csv

    (That’s 144 million records in this CSV file)

    $ head -n 5 consolidated_health_checkin.csv
    SURVEY_STATIC_ID,REGISTRANT_CODE,RESPONSE_ID,STARTED_ON,STARTED_ON_TIME,DAYS_SINCE,ABDOMINAL_PAIN,CHILLS,DIARRHEA,FATIGUE,FEELING_TODAY,FEVER,HAD_SYMPTOMS,HEADACHE,HEALTH_IMPACT,HEALTH_NOW,HEALTH_NOW_COMPARISON,VACCINE_CAUSED_HEALTH_ISSUES,HEALTHCARE_VISITS,ITCHING,JOINT_PAINS,MUSCLE_OR_BODY_ACHES,NAUSEA,PAIN,PREGNANT,PREGNANCY_TEST,RASH_OUTSIDE_INJECTION_SITE,REDNESS,SITE_REACTION,SWELLING,SYSTEMIC_REACTION,TEMPERATURE_CELSIUS,TEMPERATURE_FAHRENHEIT,TEMPERATURE_READING,TESTED_POSITIVE,TESTED_POSITIVE_DATE,VOMITING,DURATION_MINS,PREFERRED_LANGUAGE
    vsafe-0-day-dose1,222-10271-84782,s244305050865137831057660547899056617007,12/31/2020,4:55:13 PM,0,,,,,Good,No,,Mild,N/A,,,,,,,,,Mild,,,,,Pain,,Headache,,,,,,,,English
    vsafe-0-day-dose1,222-10325-02776,s258811629454233188277362395339553379505,05/19/2021,3:16:15 PM,0,,,,,Good,No,,,N/A,,,,,,,,,,,,,,None,,None,,,,,,,0.85,English
    vsafe-0-day-dose1,222-10368-05218,s256518678527351061889187968276580937945,04/27/2021,4:11:31 PM,0,,,,,Good,No,,,N/A,,,,,,,,,,No,,,,None,,None,,,,,,,0.72,English
    vsafe-0-day-dose1,222-10453-23273,s245552707728162053684731534374544736656,01/12/2021,3:31:16 PM,0,,,,,Good,No,,,N/A,,,,,,,,,,No,,,,None,,None,,,,,,,,English

    As you can see there are many columns, which we will have to decode.

    Combing through the whole file again and again is taking a lot of time on my computer. So I decided to write a python script that’ll do all analysis in one pass of the file.

    But that was taking even more time.

    So I decided to put this data into postgreSQL to do the analysis.

    $ sudo -u postgres createuser health

    $ sudo -u postgres createdb vsafe -O health

    $ cat load.sql
    SET datestyle TO dmy;
    CREATE table if not exists checkin (
            SURVEY_STATIC_ID varchar, — eg: vsafe-0-day-dose1
            REGISTRANT_CODE varchar, — eg: 222-10271-84782
            RESPONSE_ID varchar,
            STARTED_ON DATE,
            STARTED_ON_TIME varchar,
            DAYS_SINCE int,
            ABDOMINAL_PAIN varchar,
            CHILLS varchar,
            DIARRHEA varchar,
            FATIGUE varchar,
            FEELING_TODAY varchar,
            FEVER varchar,
            HAD_SYMPTOMS varchar,
            HEADACHE varchar,
            HEALTH_IMPACT varchar,
            HEALTH_NOW varchar,
            HEALTH_NOW_COMPARISON varchar,
            VACCINE_CAUSED_HEALTH_ISSUES varchar,
            HEALTHCARE_VISITS varchar,
            ITCHING varchar,
            JOINT_PAINS varchar,
            MUSCLE_OR_BODY_ACHES varchar,
            NAUSEA varchar,
            PAIN varchar,
            PREGNANT varchar,
            PREGNANCY_TEST varchar,
            RASH_OUTSIDE_INJECTION_SITE varchar,
            REDNESS varchar,
            SITE_REACTION varchar,
            SWELLING varchar,
            SYSTEMIC_REACTION varchar,
            TEMPERATURE_CELSIUS varchar,
            TEMPERATURE_FAHRENHEIT varchar,
            TEMPERATURE_READING  varchar,
            TESTED_POSITIVE varchar,
            TESTED_POSITIVE_DATE varchar,
            VOMITING varchar,
            DURATION_MINS FLOAT,
            PREFERRED_LANGUAGE varchar
    );

    COPY checkin FROM ‘consolidated_health_checkin.csv’ DELIMITER ‘,’ CSV HEADER

    $ psql -U health vsafe -f load.sql
    …
    COPY 144856043
     

    That took about 25G space as well.

    Beautiful. Now we can do all kinds of querying.

    Actually, not yet. There’s one more thing we have to do. Create some indexes for making queries easier.

    CREATE INDEX checkin_health_impact_idx ON public.checkin USING btree (health_impact);

    Now, there are some issues with this data. For example:

    ERROR: could not create unique index “checkin_pk”
      Detail: Key (response_id)=(s252082802016465320050574992159464366472) is duplicated.
      Where: parallel worker

    response_id is duplicated, although it looks like every response might be unique.

    But let’s ignore that now for an interesting query result:

     

    That’s the distribution of the Health Impact column. 81 million responses say N/A, 56 million responses include no value (null) for this column  and the tail kind of begins there.

    When I do select count(distinct(registrant_code)) from checkin; I get 9,552,127 which means only 9.5 million registrant_codes are included in the dataset. Since v-safe allows adults to respond on behalf of children, it is probably likely that there are more individuals in the dataset than the registrant_codes.

    Then I ran select count(distinct(registrant_code)) from checkin where health_impact like ‘%Get care from a doctor or other healthcare professional%’; and it returned 797,396. Which means at least 797K people checked this option (with or without other options)

    Now let us look at the variable of interest, healthcare_visits. The query I ran is select healthcare_visits, count(*) from checkin where health_impact like ‘%Get care from a doctor or other healthcare professional%’ group by healthcare_visits ;

    The result is

     

    Note that I haven’t deduplicated by registrant_code here. 

    So I tried a different query: select count(*) from checkin where healthcare_visits  like ‘%Hospitalization%’; the answer to which is 83,690.

    Let us try deduplicating by registrant_code on that:

    select count(distinct(registrant_code)) from checkin where healthcare_visits  like ‘%Hospitalization%’; returns: 71,911

    Which means, there’s some amount of duplication in the row data as to registrant_codes and reports. In other words, from the same registrant_code, you can have multiple reports of Hospitalization.

    This data is rather messy and I’m not exactly sure how icandecide is arriving at “individual” in their numbers because all I see are registrant_code.

    Now, on to some more interesting stuff. What is the distribution of systemic_reaction in registrant_codes who reported Hospitalization?

    select systemic_reaction, count(distinct(registrant_code))from checkin where healthcare_visits  like ‘%Hospitalization%’ group by systemic_reaction ;

    That turned out disappointing because the result was 68,170 NULL fields.

     

     But among the non-null fields, “None”, “Fatigue or tiredness”, “Headache”, etc are leading. (Do note that this is a multi-value column and there could theoretically be a symptom that appears in the tail of this column multiple times thus occurring more number of times than these ones.)

    I also looked at the other files available for download.

    It seems like the Consolidated_health_checkin_u3[1].zip must be under 3 children. The consolidated_registrants[1].zip file makes me think that each registrant_code actually uniquely identifies an individual. Because children are having separate registrant_code with guardian registrant_code mapped in this file. The other files are about race/ethnicity and vaccine that was administered.

     

    The under 3 file includes 116394 reports. Some of the discrepancies in number between my analysis and ICAN’s dashboard probably comes from them adding both these together. 

  • Decommissioning Technology Centered Theories of Change

    If you look closely, many theories of change in public health where technology is involved has, at its heart, the following idea:

    Adopting Technology -> leads to -> Better Health

    This is a meaningless assumption guided by the hype around what technology can accomplish and the wishful thinking on solving large problems.

    Firstly, technology is a large, amorphous, heterogenous categorization of human innovations. There are thousand different kinds of technology. One could say anything that human beings have made is technology.

    Wikipedia says: “Technology is the sum of any techniques, skills, methods, and processes used in the production of goods or services or in the accomplishment of objectives”

    Oxford dictionary says: “scientific knowledge used in practical ways in industry, for example in designing new machines”

    Here is a list of things. Pick the ones you think are technology:

    • MRI machine
    • Stethoscope
    • Instant messaging app like WhatsApp
    • A paper tea cup
    • Polio vaccine
    • Mobile phone
    • Solar panel
    • Wallet
    • Pen
    • Clothes
    • Fishes
    • Scissors
    • Fan
    • Ubuntu linux
    • Paracetamol
    • Breast milk

    Generalizations like “adopting technology will improve universal health coverage” are as useful as saying “human innovations will improve universal health coverage”.

    The second problem with the unquestioning acceptance of technology is that technology isn’t always positive, or even value neutral.

    • Nuclear bomb
    • Pegasus spyware
    • Deepfake
    • Fake news bots
    • Addictive apps
    • Fossil fuel
    • Heroin

    Now if you are a tech-bhakt, your primary reaction to the above list is “Oh, but you know, these are just harmful uses of an otherwise good/neutral technology. It is a human problem, not the technology’s problem.” But please read on carefully.

    The world we live in is populated by an increasing number of human beings. And human beings interact with technology in many ways. Some are predictable, some are unpredictable. The effect that a technology has on anything cannot be assumed to be “universally positive”. That effect has to be studied and understood.

    That is not an argument against developing technology. It is an argument only against how technology is advertised and incorporated into human life. Technology should not be pushed into systems without weighing the potential advantages and potential harmful effects it can have. Such push can be counter productive if the real harms outweigh the real benefits.

    Any use of technology will lie in a spectrum that ranges from extremely beneficial to extremely harmful. It takes discretion to identify where on the spectrum it lies. That human discretion, rationality, and scientific temper is what we need to develop in theories of change surrounding technology in public health.

       ***

    Now that we have accomplished that technology in public health needs to be evaluated on an intervention-by-intervention basis, we can look at some specific examples.

    Digital (enabled) delivery of healthcare

    This vague concept is a slice of the “technology” concept we discussed above. Digitally enabled healthcare delivery can mean anything. Is it digitally enabled if I use a digital thermometer or a digital blood pressure device? Is it digital delivery if I’m doing a consultation over WhatsApp video call?

    Let’s take a plausible example. A hospital information management system with electronic medical records and teleconsultation. This probably is something that many people have in mind when they’re talking about things like “medical and diagnostic connectivity throughout life course for every individual” or “sophisticated early warning systems leading to better preventative care”.

    That example brings up a lot of questions. Which hospital are we talking about? Where is it located? Who are the beneficiaries and users of these? What kind of skills are we talking about? What kind of resources are available in these settings? What costs in terms of attention, time, effort, fatigue, etc are involved in utilizing these systems? What kind of software is available? How practical are the benefits? What are the challenges in taking data out of an EMR system and building early warning systems out of it? What foundational technologies are we lacking to build such systems? How will data from EMRs be analyzed? Who will do the analysis? What are the political processes occurring in India which could be connected to these? What are the incentives given to private sector in this? What are the protections required for patients? What are the support structures required for healthcare workers? Who is this intervention aimed to benefit? How does it affect health equity? Is it solving a problem that has been expressed by the community that it is being incorporated in?

    These and countless other questions have to be answered before considering whether an intervention like above will lead to the impact that it is assumed to produce. Now, as is evident from these questions, the answers will vary widely depending on the settings. It might (or might not) produce an overwhelmingly positive impact in a super-specialty hospital in Koramangala for a software developer working with Infosys. It might not produce a similar impact in a PHC in Koppal for a NREGA dependent person. Unfortunately a lot of Indians are of the latter kind.

    Techno-legal regulations

    Here is another vague slice. Of course technology has to be regulated. Technology has always been regulated. It is just some newer technologies which are only slowly getting regulated. Things like databases and software platforms. The concern that regulations try to address in here are “Citizen rights, privacy and dignity”, “reducing technological inequities, algorithmic bias”, etc.

    But “regulations”, like “technology” are not a sure-shot solution to anything. A lot of regulations stifle technology but doesn’t help fulfill the purpose it was meant to be either. Take the telemedicine guidelines released in March 2020, for example. In an attempt to enable telemedicine, it restricted the kind of diagnoses and prescriptions that can be made over telemedicine.

    Getting regulations right is super hard. In the case of software based technology, even when regulations are right and tight, people tend to find loopholes rather quickly. Because software can quickly be adapted, it is possible to follow regulation and still continue doing bad stuff. Take how after GDPR came into place requiring consent for cookie use, so did dark patterns in cookie consent pop-ups.

    India has a government which went to the Supreme Court to argue that privacy is not a fundamental right. When the government itself is involved in treating human beings as citizens to be controlled through surveillance, what insulation can regulations provide to human rights like privacy?

    In other words, “equitable, people-centered and quality health services” and “improved accountability and transparency in the health system” cannot come through techno-legal solutions when the democracy does not have those in its priority list. Surely, technology and law can be instruments of social transformation. But only in the right hands.

    There is no question of equity and people-centeredness emerging out of a process that does not have representation of people in it. What about quality? There are already some frameworks for quality in healthcare service. NHSRC, NABH, etc have various accreditation policies for hospitals. It takes a lot of work to build a culture of quality in a complex organism like a hospital, let alone health system. Culture is not something technology can fix.

    Technology can be omnipresent. But a human cannot yell at a machine to get justice. That technology can lead to better accountability is a dream. The game where technology rapidly adapts to regulations and finds loopholes – human beings are 10 times better than machines in that game. Any accountability system based on technology will be gamed by human beings.

    To see how technology and law affects transparency, one just has to look at what is happening to Right To Information act in our country today. No matter how “sophisticated” our technology gets, human beings are going to remain human beings.

       ***

    And that is where “trust in the health system” comes in. How should human beings trust a system that doesn’t listen to them, negates their experiences, puts barriers in front of them in accessing healthcare, reduces health to the singular dimension of curative services (or recently vaccinations), treats them as undeserving, and regularly intrudes and violates their right to life and bodily integrity? What app should they install to download some trust?

    Discussions on technology in public health need to wait till we discuss who our health systems are for. And once we have an answer on that, we should invite those people to the table. And when they state the problems that they face in leading a healthy life, those are the problems to be solved. Work backwards from there and you’ll realize that a lot of what we have are problems that don’t require technology to command citizens, but instead require human beings to listen to human beings.

  • Scraping the Bottom of the Pyramid in Indian Healthcare

    At least 300 million people in India live below poverty line. And that line is drawn somewhere around an income of ₹1000-1500 per month. If we draw the line double that, the number of poor also doubles.

    That’s the bottom of the bottomless pyramid.

    Half a billion people who earn less than ₹3000 a month.

    If you earned that much, what would your priorities be? Food? Shelter? Financial security? Education for a child?

    What about your own health? 

    Imagine you have diabetes too. The cheapest food you have all around you is rice or wheat based. If you want to decrease carbohydrates and not go hungry, how much can you spend on food? And if your sugars are not under control, would you spend more on a combination of multiple oral hypoglycemic agents that might cost about ₹500 per month?

       ***

    Scraping the bottom of the pyramid works beautifully in consumer goods. You build something dirt cheap for the poor. Take a ₹2 shampoo sachet. You can cut down the size of the sachet to make it even cheaper.

    You can’t sell half a metformin tablet to a poor diabetic.

    You can’t prescribe a 1 day course of antibiotic.

    You can’t cure pain with an injection.

    But you can. Indeed that’s the kind of healthcare that those at the bottom of the pyramid currently receive. Sub-standard, inappropriate, and incomplete.

    Because healthcare, unlike consumer goods, doesn’t become cheaper at the bottom of the pyramid. It actually becomes more expensive due to the intersection of vulnerabilities.

       ***

    There is simply nothing to scrape at the bottom of the pyramid for healthcare.

    Someone else has to pay.

    A third party.

    Could be the government. Could be charity. Could be grants.

    But hey! If someone is paying, does it matter whether it is the beneficiary or a third party? 

       ***

    That’s the logic with which most NGOs in health and government facilities work.

    Three boxes. Right most one says "govt, others". Arrow from that which goes to the second one reads "pays". Second box reads "Healthcare". Arrow from that to the first one says "gets". First box says half a billion.

    Say you’re a doctor in a PHC. The government pays you. You deliver healthcare to the poor. Simple economics.

    Where does the government get money? It raises money through taxes, etc.

    What if you’re a non-governmental organization? You get donations/grants in what is called “fund-raising”.

    (There’s of course a cross-subsidization model which may look different superficially, but isn’t very different in the larger scheme of things)

    Is this any different from first party payment?

    Similar figure as previous. Only two boxes here. First box says "those who afford". Second box says "healthcare". Arrow in between to both sides - "pays" and "gets"

    Very different!

       ***

    The first issue is that of accountability. Accountability lies where money flows from. If my healthcare is paid for by someone else, my healthcare provider isn’t accountable to me.

    Public health facilities are not accountable to the poor that it serves healthcare to. They are only accountable to the hierarchy above them.

    NGOs are not accountable to the poor that they serve healthcare to either. They are only accountable to funders. (Typically NGOs which are able to diversify their funding source is able to decrease the power that funders have to some extent by dividing the funders into many).

    Why, though? Because accountability without control doesn’t work.

    If you want to hold someone accountable, you have to be able to control them in some way.

       ***

    When there is no accountability, the next issue is that of quality.

    In first party payment, quality assessment is decentralized. Every individual makes their own assessment about the quality of care they receive. And this instantly translates to payment, recurring visits, etc.

    In third party payment, quality assessment is different. It uses “metrics”. And metrics are difficult. Funders typically look at fancy metrics like “decrease in maternal mortality rate”. The problem with such “key” metrics are that they capture very little nuance and sometimes no meaning.

    To government, for example, where the whole hierarchy is just supplying metrics to someone else, it becomes a complete number game. (Recommended reading: Chasing Numbers, Betraying People)

    To NGO funders who have a bit more involved staffing structure it goes beyond numbers to also include “reports” filled with presentation-worthy photographs.

    It no longer matters whether the individual receives quality healthcare as long as the metrics and reports are looking good.

       ***

    Now let us look at something totally different. The CSR sector spent about 2600 crore rupees in health in 2020-21 FY. That’s about 1% of India’s national health budget. As per national health accounts 2017-18, the combined contribution of NGOs, corporates, foreign aid, etc to India’s health expenditures is less than 10%. 

    By all means, the government is the single largest provider and payer of healthcare for the bottom half of India’s pyramid.

       ***

    If you read all of this together, there are certain insights to be gained about why certain things are the way they are.

    Why do NGOs build/research “models”? Because the kind of money it takes to deliver care to a population larger than what “model”s serve is hard for NGOs to come by.

    Why does everyone want to build software? Because software can (theoretically) “scale” to large populations without a lot of money.

    Why do NGOs focus on showcasing “reach”? Because numbers mean impact for funders. And creating the impression of quality is more important than quality.

    Why does public health system get away with delivering poor quality healthcare? Because there’s no real way citizens can hold health system accountable. The constitutionally mandated way they can do so has been hijacked by issues like religion, party, and war.

       ***

    What to do about all this?

    1. Look deeper than numbers – everywhere. In fact, don’t look at numbers, at all. Numbers are meant to hide and deceive.
    2. Think critically. Especially on stories around impact. Reach isn’t impact. Touch-points aren’t healthcare. Technology can’t solve problems that technology can’t solve. Innovation is a buzzword unless and until innovation leads to inclusion.
    3. Be political. In thoughts, actions, and choices.
    4. Be aware, call out, and discuss things like above with raw honesty. Reality is shaped by what we accept silently.

  • Objective Assessment of Primary Healthcare Leadership

    In our primary healthcare leadership fellowship that’s been running for 2 years now, we’ve only used self-assessment by fellows as a measure of impact till now.

    While self-assessment is the easiest to perform and also gives a good sense of subjective measures like confidence and readiness, bringing objectivity to the measurement of impact is important for academic rigor.

    The subject of measurement here is leadership. How do we objectively measure leadership and/or growth in leadership?

    For that, it becomes necessary to define leadership in some way. Fortunately, there’s an article that RK keeps showing everyone which details 6 roles of a family physician. 

    The roles are

    • Care provider
    • Consultant
    • Capacity builder
    • Clinical trainer
    • Clinical governance leader
    • Champion of community orientated primary care

    We can define primary healthcare leadership as excellence in all these roles. It is easier to develop objective measures for some of these at least.

    Here are some examples:

    Capacity builder – How many practitioners are being or have been mentored/supported by the practitioner?

    Clinical trainer – How many workplace trainings have the practitioner conducted in the past 3 months?

    Champion of community orientated services – Has the practitioner worked with the community to develop/promote any community based service?

    It is important to evaluate these at the baseline, incorporate growth in these dimensions as an expectation during the onboarding process, and re-evaluate these at the end of the fellowship to get an objective metric of leadership growth.

  • With Great Power Comes Great Accountability

    Where should the line between ‘doctors should be held accountable for medical malpractice’ and ‘doctors are humans and they can make mistakes’ be? [Source]

    There is a world where this dichotomy/binary is not entirely false – medical negligence/malpractice jurisdiction. And the courts in such cases have a very nuanced approach to this question. For example, here is what the consumer court says:

    What is medical negligence?
    Negligence is simply the failure to exercise due care. It occurs when a doctor fails to perform to the standards of his or her profession. The three ingredients of negligence are as follows: 1. The defendant owes a duty of care to the plaintiff. 2. The defendant has breached this duty of care. 3. The plaintiff has suffered an injury due to this breach.

    What is medical malpractice?
    A medical malpractice is a claim of negligence committed by a professional health care provider — such as a doctor, nurse, dentist, technician, hospital or hospital worker — whose treatment of a patient departs from a standard of care met by those with similar training and experience, resulting in harm to a patient or patients.

    Does someone who is not satisfied with the results of their surgery have viable medical negligence claim?
    In general, there are no guarantees of medical results, and unexpected or unsuccessful results do not necessarily mean negligence has occurred. To succeed in a medical negligence case, a consumer has to show an injury or damages that resulted from the doctor’s deviation from the standard of care applicable to the procedure.

    These are intentionally vague about what the “standard of care” is supposed to be. Because it would be very unwise to define that in law. The only people who can reasonably inform a court whether a particular care delivered is standard or sub-standard is a group of experts (a group of doctors practicing that kind of care). That’s a double edged sword though.

    Because, for one, it puts doctors at an advantage. It is their own kind who will decide and therefore there is a conflict of interest in the design of the system itself. But on the other hand, this system can ensure that every case is judged through a medical practitioner’s gaze rather than through an outsider’s gaze.

    When it comes to practice, there are a few imperfections in the system.

    1) Doctors are sometimes the worst allies of other doctors. In many negligence cases, the group of doctors who inform the court on whether the standards of care have been met or not, intentionally raises the standard of care (with the benefit of hindsight). This has disastrous consequences for the doctor involved in litigation.

    2) It is difficult to navigate the legal system. The consumer court is the best place for patients to approach in the case of medical negligence issues because the patient is the favored litigant in consumer courts. These courts exist for the consumer and by default take their side. The other fora – medical council and criminal courts – are places where it is very difficult for a patient to win. And that would explain the low number of cases registered in such fora. I couldn’t find official statistics in consumer court websites, but a researcher claims that there were 3241 cases registered in consumer courts throughout India in 2018, and 2638 cases in 2019. I would think those numbers are true – yet they are very very low.

    But it would be a great mistake to rely on the legal system to improve healthcare. Law should often be the last resort to many complex social issues – because it is very difficult to get the law right in such situations. And case-by-case approach like in medical negligence above puts great stress on the legal system (if there are enough number of cases) which in turn leads to bad outcomes for whoever gets tangled in a case.

    For example, there are ethical issues where taking a side is not straightforward. Take the case of Ayurveda prescriptions by modern medicine practitioners. There are doctors who think that whatever satisfies a patient’s goals about their health is medicine. But there are doctors who would rather let the patient suffer than give up their ego regarding “evidence”. And then there are doctors who think that anything modern medicine throws up is evidence based and prescribe mercilessly.

    These are fundamentally hard ethical conundrums. Do you take every doctor who doesn’t agree with your way of thinking to the court? That’d be a good way to waste your life.

    There are solutions which work out much faster. Outside the courts.

    One is activism. Activism is where you constantly make noise and draw attention towards a particular cause. You can be as creative as you want. You can use various tools. But the end goal is that people start caring about your cause. This is political. And there will be lots of political opposition too. In issues where one side is completely non-existent, activism has very big impact in putting that side up as an equal cause. For example, in today’s India, patient rights is something that’s rarely discussed in healthcare. And activism on that is probably very helpful.

    Then there is frank politics. This is the kind where you influence an MP who’s kind towards your cause to raise the issue in Parliament or in the public sphere. Basically, politicizing an issue. Inviting the opposition leader to a protest is the sure-shot way to politicize something.

    Journalism works too. Journalism is kind of like activism in this case. But the advantage with journalism is that it is perceived more like research than like activism. There is a “truth” value to journalism. A lot of people consume journalism and take it to be “truth” by default. Propaganda in such spaces is very effective on such people.

    Research is another option. This gives an academic clothing to your advocacy. It legitimizes every other method by making them more “scientific”. Research takes considerable amount of investment, but if you are dedicated to one particular topic, you may as well wear this garb.

    There are probably many other things one can do to improve healthcare from outside courts. But these are just examples to show that we need not rely on courts/law for this.

    What should these methods of advocacy take up as their cause? I think a focus on accountability is a good thing. And by accountability, I do not mean a system where a scapegoat is found and suspended.

    Let me describe accountability with an example. In VMH, we used to do mortality meets. We meet, with all the relevant people present. We take deaths which happened after the last meeting. There is a person who leads the meet who would have identified a few cases where there is something critically wrong with the care delivered. The participants then discuss various concerns related to how that came about. They then find and fix critical issues in the system which contributes to the problem. Trainings on specific topics get scheduled, devices are bought or fixed, staff pattern is changed, physical layout of the hospital is changed, triage system is changed, … anything and everything that can be changed for a better outcome in the next patient is identified and possibly changed.

    Where is the accountability in this? The accountability is in a group of people who think it is the responsible thing to do to conduct a mortality meet. When they are working towards fixing the systemic problems. When they hold themselves responsible and do everything in their power to change things. That’s accountability.

    Lack of accountability is best demonstrated by the RTI responses of our government regarding COVID management. Wherever the government has said “we do not have the data” they are showing exemplary lack of accountability. That it is okay to say “we do not have the data” means that they assume no accountability of what is going on. That it is okay to blame someone else is the hallmark of lack of accountability. When someone takes accountability, they say “I have done this, this, and this, and I’m waiting for this, this and this.” When someone doesn’t take accountability they say “But my hands are tied.”

    Advocacy should be aimed at bringing in accountability in all parts of the healthcare system. Education, governance, administration, healthcare delivery, etc.

    Who should do such advocacy? Who should be responsible for healthcare system in India? I have written about it previously.

    Sure, change is slow. Some work requires generations. But, we can’t not
    do what we should be doing, right? We should start by holding ourselves
    accountable, by asking us what we can do and what we are doing. That’ll give us greater courage in asking others to be accountable.