Blissful Life

Category: social

  • Engaging with the System – A Visit to IISc

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

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

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

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

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

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

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

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

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

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

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

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

    But that won’t pass the vibe check.

  • Personal Is Political in Professional Practice

    “Should a doctor treat an alcoholic who is injured due to drunk driving? Would your opinion change if it were just a solo accident v/s injuring/killing other people on the road?” asked @arshiet. The regular controversy. Should doctors judge their patients? Is it ethical to even ask the question of whether it is ethical for doctors to withhold treatment to anyone? What are the social determinants of alcohol use?

    The issue is straightforward in the emergency room. You save life first and worry about alcohol and justice later.

    But what about elective issues? If you are an obstetrician and you are pro-life, do you avoid elective abortions? If you are a pediatric surgeon and you consider circumcision as genital mutilation, do you avoid ritual circumcisions? Conscientious Objection – apparently that’s what it is called.

    One of the solutions offered is that the healthcare provider can be upfront about the moral position and arrange a different provider. This helps the patient to retain autonomy and the provider to retain moral clarity.

    Basically, doctors can’t simply cancel patients.

    If we refuse to see the doctor-patient relationship as special, we can see that what’s at play here is the tension between “personal is political”, cancel culture, etc on one side and the practical realities of the world on the other side. I’ve personally gone through the self-isolation of ideological purism and come out with the ideology that it is okay to be altruistically pragmatic.

    The world is full of people with incompatible ideas, values, and norms. If we start cancelling, we end up cancelling almost everyone. If we don’t cancel, we become an apolitical mess. The point is then about finding alternatives to canceling everyone. You cancel some, you strategically avoid some, you engage sincerely with some others.

    That intelligent, “nuanced”, intersectional approach to politics is called life.

  • 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.

  • 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.

  • Don’t Let Them Dehumanize You, Doctors!

    The society will try to dehumanize you in various ways. And you will feel pressurized to play along too. Don’t let them do that to you, as much as possible.

    —

    Every patient comes to you with the expectation of a complete cure. They do not care that you are human. Reset their expectations. Let them know that there are limits to what you can do. Stay human.

    Once, I was second call in VMH when a patient was brought dead to the hospital. The doctor on duty wanted to send them home in the same ambulance they came in so that they don’t have to be bothered about arranging transport. But the relatives were getting angry that the doctor is not trying to save the life of the patient. I was called in. The patient was “obviously” dead. But it wasn’t that obvious to the people who loved the patient. They were expecting an omnipotent doctor to be able to bring the patient back from dead.

    People will always come to you with unreasonable expectations – whether they express it or not. Preemptively address those and reset those expectations. Don’t let them dehumanize you.

    —

    One patient sees one doctor a day. One doctor sees many more patients a day. Patients do not know this or do not care about this. Each patient thinks that it is reasonable to expect that the doctor prioritizes their care above everyone else’s. Omnipresence is not human.

    When dealing with multiple patients and feeling overwhelmed, let each of your patient know about your situation and limitation. Before they get a chance to complain that you’re not giving them the care they deserve, let them know that you are thinned out and helpless.

    There is a limit to how many patients you can care for. The society wants you to treat this limit as adjustable with a bit of overwork. Don’t let them dehumanize you.

    —

    You might have been taught that it is unprofessional to express emotions in your duty. But it is very human to have emotions.

    There’s a trick I use with anger. I don’t lash out on people with anger. But I tell patients that I’m angry or that something they’ve done or are doing is making me angry. There’s no easier way to communicate!

    I have also used “I am feeling anxious about …”, “I am scared that …”, “It makes me sad too that …”.

    Put a label to your feeling and put it across to your patient. Let them know. Let them know that you’re human. Don’t let them think that you are not.

    —

    You can’t know everything. You can’t remember everything. Open textbooks in front of your patient. Show them the search terms and the apps you use.

    Tell them that you will have to look the answer for that up. Ask them for links to the articles they read to reach at their own internet-guided-diagnosis. I’ve more than once been linked to cutting edge research that I wasn’t even aware of.

    Don’t let the unreasonable expectation of a charismatic omniscient doctor dehumanize you.

    —

    You need to eat. You need money. Whether your patients are rich or poor doesn’t change those facts. But that’s not what the patients think. They think of healthcare as a profitable business. They think of healthcare as a necessary service. They expect you to sacrifice profit. They expect you to sacrifice compensation, even.

    Show them the reality. Show them how you’re saving them money by giving them the right treatment. Show them the expenses you incur in doing so. Tell them how the one hour you just spent with them is already heavily subsidized. (If you don’t realize this, just answer this question after a minute of thinking. “How much, would you say, is an hour of your time worth?” And when you answer it, make sure you account for the opportunity cost you incur by not doing other things that you’re capable of doing.) Give them a lesson in economics. 

    Let them know that it’s not omnibenevolence, but it is self-love that is human.

    —

    Don’t look at the patient-doctor relationship as a purely biomedical one. It is a deeply political one. And a deeply human one. It need not be one way. It should not be one way. Anything that comes in the way of making it complicated needs to be given considerable time and addressed.

  • Whose Responsibility is Health?

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

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

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

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

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

    But this definition is not just restricted to doctors.

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

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

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

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

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

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

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

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

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

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

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

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

    But there are some important counter-arguments

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

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

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

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

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

  • Wonder Regimen to End Tuberculosis in India

    Have you ever looked at Tuberculosis and thought, “Hmm. I wish there is a way to end this disease”?

    Well, wonder no more.

    Anurag Bhargava, Madhavi Bhargava & Anika Juneja have come up with a regimen that can achieve your dream.

    Another good news is that treatment with this regimen can also be helpful in many other diseases.

    Even better, it is a non-invasive regimen.

    Want to learn the regimen and start using it in your practice?

    Click here [PDF, 1.9MB] to know more. (You might want to skip to the end for the actual prescription, but read the full paper for context).

    Dr Anika Juneja, one of the authors of this paper, has won the India HPSR Fellowship this year.

  • 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?

  • 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?