Blissful Life

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

Category: system

  • Repeated Names in NSQ Manufacturing

     There’s a 2014-2016 survey of drugs.

    That’s followed up with smaller surveys by CDSCO.

    We will compare with March 2023 report.

    Let’s look for repeated offenders.

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

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

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

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

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

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

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

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

    Ridley is there once in this list too.

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

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

    Shiva Biogenetic Himachal Pradesh is back here too.

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

     

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

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

  • 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

  • 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.

  • 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.

  • Changing The “System”

    People of all kinds routinely blame the “system” for many things. They’re absolutely right. It is the system that shapes human behavior. In a system where certain behaviors are rewarded, those behaviors are repeated. And vice versa. We are all Pavlov’s dogs in that sense.

    That’s why awards and honors are instituted. To reward the right kind of behavior even if that’s not the expected norm. Awards motivate extraordinary people. What motivates ordinary people? The system.

    The “system” is the system that encourages and supports ordinary people to do things that they do in their ordinary life.

    The system includes written laws, unwritten laws, stereotypes, hierarchies, economic condition, political condition, geographic and physical condition, infrastructure, feelings, mythology, myths, news, fake news, communication, … literally everything you can think of forms the system.

    Who builds the system?

    The naivest answer to this and the most convenient answer for “ordinary” people is to blame politicians for building the system. This is especially true for people who consider themselves apolitical. Sadly their politics is that of selfish avoidance of responsibility. It is not always the fault of intention. People who can’t stand oppression and feel like there is so much to do that they cannot be responsible for any of it will unconsciously try to talk about why it is not their responsibility. But often it is selfish laziness.

    The better answer is that “we” build the system. Who are we? Anyone who can be involved in building the system builds the system. By commission or by omission.

    Who can change the system?

    Intuitively, the people who built the system can change the system. True. But not all have equal role in building the system. Neither do all have equal say in changing the system. The people who can change the system the easiest are the people with most agency, privilege, and voice.

    Who can not change the system?

    People who become a slave to the system, who sacrifice their agency, privilege, and voice to the system instead of questioning it. They absolutely cannot change the system.

    Why does the system perpetuate?

    Because it is easier to continue the system than to change the system. Anyone who wants to change the system has to find ways of sustaining and motivating themselves. Then they have to question the system and work against it. They have to do this at the peril of losing access to their accustomed rewards from the system. They have to stand up against their acquaintances who enjoy the benefits of the system. They have to shake things up. They have to stand out. They have to put themselves at great risk.

    The biggest enemies of people who want to change the system are the people who do not want to change the system. The people who benefit from the system usually do not want the system to change, because of inertia, even if they superficially blame the system for everything.

    How to change the system?

    If you agree with most of what I said above, the answer to this is straightforward.

    Prerequisite: Have a lot of privilege. Have the mental space to take on challenging things. Have help, support, guidance. Have plan B, plan C. Privilege is a gift.

    (An aside on privilege. A lot of the privileged folks think that they’re not privileged. When they hear the word “privilege” they imagine Mukesh Ambani’s inheritance with Narendra Modi’s popularity and influence. If you can read this blog post, you’re already more privileged than a lot of people on this planet. Reading is a privilege. English is a privilege. Internet is a privilege. Time is a privilege. Sure you might be facing oppression in many ways. But that doesn’t take your privileges away. Everyone on the planet faces some or the other oppression, and a lot of them face more oppression than you do. It is a lot easier if you count your privileges and use them.)

    The first step is to find loopholes in the system to build yourself sustainable income outside the parts you want to change. This might look like joining pre-existing teams doing what you want to do, finding scholarships or grants, monetizing on a rare skill, etc. Creativity is key here. If you do not have any privilege that you can leverage to achieve this step, then you’re out of luck. The best thing you can do is continue being part of the system and silently help those who are trying to change the system.

    The next step is to find motivation. There is so much to do and so many generations worth of work. Find problems that you can solve. Find problems solving which will give you satisfaction. Find cracks that make it easier to break the system. Define short-term successes. Think and act with purpose.

    Then help others who want to do the same. Amplify voices. Volunteer effort. Offer support. Build friendships. Build capacity. Build community.

    Things not to do

    When thinking idealistically, it can be easy to develop hatred to those who are doing things differently from you. If people are trying to change the system and they are doing it in a way that you do not approve of, engage in respectful debates with open mind. Sometimes they might be doing it right and you are wrong and you can change your ways. Sometimes vice versa. Sometimes both of you can find useful elements to do things differently. Even when there are unsolvable disagreements, it is easier to think about those as fundamentally hard questions with no one right answer. Do not develop hatred for people who do things differently.
    Do not become intellectually arrogant. Intellectual humility is when you keep your intellectual outlook about the world detached from your ego. And you’re ready to take a hit on the outlook at any moment. And you’re willing to change them. Intellectual arrogance is when you refuse to change your outlook from what you formed in early adulthood.
     

    Validity of this strategy

    This may not be the only way to do things. But this seems like a reasonable way, to me, at the moment.

  • 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.

  • “Risks” vs Risks

    Decision making is almost always complicated by uncertainties. The more information that can provide context, the more stakeholders that are part of the decision, the better the chances of reaching a good decision.

    In the past few weeks, world leaders have had to make very difficult decisions. Lock down entire country? Put money into healthcare? Risk economic disasters to prevent health disaster?

    I guess the biggest problem they would have faced in making these decisions is uncertainty. Because medicine is a field of uncertainties. The first thing a doctor learns when helping patients is that they can never be sure of anything other than the fact that they have to act. Diseases, cells, organisms, molecules, environment, human behaviour – there are a lot of moving parts in medicine. Parts that you can’t control. Parts that you can’t even predict.

    A doctor is a performance artist who uses an imperfect science to help alleviate suffering. In Osler’s words, “Medicine is a science of uncertainty and an art of probability”. I’ve been fascinated by the range of dilemmas a thinking doctor faces in routine practice. When choosing who gets a ventilator they get to act God. When choosing what information to convey to the spouse of a person newly diagnosed with HIV, they get to play the Supreme Court. And not to forget the countless times they get to act human when seeing raw humanness play out in various scenarios – first breastfeeding of a newborn baby, last bye-byes before surgery (oh, thinking of it, I’ve never seen a family wave bye-bye in India. Maybe I’m watching too much of medical TV series), pain that persists even with the strongest painkillers, so on.

    We were talking about uncertainties. Yes. That’s what makes life really difficult in the field of medicine.

    Let’s take one specific question. The use of masks by public during COVID-19 pandemic. Should they wear it? Should they not?

    Let me break it down.

    What do we know about how the virus is transmitted? Just enough. We think it is through respiratory droplets and contact.

    What does that mean? A respiratory droplet is any drop that comes out of a person’s nose or mouth. It could come out while coughing, sneezing, even while laughing, or shouting. Contact is, well, contact. Touch. Touch anywhere where those respiratory droplets could have been. Surfaces, hands, wherever.

    Okay. So we know how the virus comes out of a person. But how does it enter someone else? No points for guessing that the respiratory tract is a major route for entry of respiratory viruses into someone. That includes mouth and nose. But turns out respiratory viruses can enter body through eyes too. (Warned you about uncertainties, didn’t I?) Luckily for humans, the largest organ of our body – the skin – is also a very protective sheath that makes our hands, legs, and so on less likely to be ports of entry for the virus. (Like I tell the people who come to me scared of HIV because they touched someone infected with HIV, even if a bag of blood full of HIV falls on your bare hands, unless there is a cut on your skin, there is no need to be scared. Of course, they then ask about the possibilities of microscopic cuts. But that’s another story and this snippet of that story is included to make a point that there are “risks” and there are risks.)

    Now, what do we know about masks? The medical masks that we are talking about? They can definitely protect someone’s nose and mouth from other people’s respiratory droplets. But that’s all they can do. They cannot protect their hands. They cannot protect their eyes. And the mask itself gets contaminated while protecting the mouth and nose of the wearer (Important point. The external surface of the mask is where all those respiratory droplets, if any, should get caught).

    What do we know about people? We know that people touch their face a lot. You just touched your face while reading this article. Your nose is itching as you’re reading this sentence.

    When a human goes out during the pandemic to buy grocery, they have to deal with many things. Around them, there could be a large number of people who have never seen SARS-CoV-2 in their life. They could also be walking among asymptomatic carriers who are shedding their virus in respiratory droplets. They could be touching surfaces which a carrier coughed into 10 minutes before. They could be inhaling respiratory droplets from carriers. Respiratory droplets could land on their eyes. Droplets could land on their hands and they could then touch their eyes/nose inadvertently. Droplets could land on their masks and they could then touch their masks inadvertently. Their mask itself could be a makeshift one with towel that they hold in front of nose and mouth (where the external most surface is their own, pretty, hand). And that hand could then inadvertently touch their eyes/nose.

    Do you see the risks and the risks that masks mask (pun intended)?

    Yes, theoretically masks decrease the risk of transmission by a tiny bit. But practically, probably, they don’t.

    On the other hand, there are some real risks of people wearing masks to grocery shops.

    The first thing that happens is we all run out of masks. Including the health care workers and people who care for COVID-19 infected at home. (Of course this has already happened in many cities). These people are now at definite risk for contracting infections because they deal with definitely sick people and for very long durations which increases their exposure. Many of the health care workers do not become sick, but some of them do. When they become sick the entire system is demoralized. And we don’t want that to happen when we are about to face a pandemic that nobody is sure how to deal with.

    That is why WHO and CDC and others insist that masks should be used rationally.

    Does that mean, if we had unlimited supply of masks, it would be okay for public to wear it when going out to fetch grocery?

    If you are a person who wears a helmet while walking on the road, yes.

    Of course, how could I miss this, yesterday when I went to the grocer’s, I was wearing a helmet with the glass visor closed all the time.

    — Akshay S Dinesh (@asdofindia) March 28, 2020

    Okay. Update: I haven’t considered at all the chance that you’re an asymptomatic carrier who is spreading the disease to others. In which case, suddenly there is a non-trivial effect where masks prevent the respiratory droplets from getting out of you in the first place. Uncertainties here are the proportion of asymptomatic carriers and their infectivity.

    I really don’t know.
    Update on May 30: There is piling evidence that masks are useful for source control. And now that the pandemic is well distributed inside all countries, the calculations of risk also has to change. Right now, the governments would have had enough chance to ramp up PPE production and meet healthcare needs. Right now you are at a higher risk of being an asymptomatic carrier than you were at the beginning of the pandemic when overall prevalence was low. So, yes, wear a mask. It may not protect yourself, but it will protect others.

  • The Case of Dr Payal Tadvi or the Case of India’s Healthcare System?

    Dr Payal Tadvi committed suicide exactly a week ago. She was a postgraduate student in Obstetrics & Gynecology. Investigation is going on about the death. There are quotes from family members that she was being harassed on the basis of caste by seniors. Those seniors have written their side blaming workload. (Please go through the links if you do not know the details)

    Let us leave them aside and ask ourselves a few questions now.

    Is their discrimination in medical colleges?
    There is. All kinds of it. Economic capacity. Skin tone. Age. Seniority. Language. Region. Residence in the state where the medical college is in. Category of seat. Every damn kind of discrimination. There is discrimination in medical colleges.

    Is their caste-based discrimination in medical colleges?
    I think the answer is yes. I haven’t seen much first hand. But, there is definitely discrimination based on reservation. And since reservation is based on caste, it can indirectly be told that this is caste-based discrimination (I guess).

    Reservation is seen as giving unfair advantage to people. People who get their seats through reservation are seen as people who do not deserve the seats. When they get low marks this is brought up again as the reason (and not that most people end up with low marks in medical colleges, no matter which kind of seat they got while entering).

    Is their excess workload in medical colleges?
    Undoubtedly, yes. This is a complete failure of the public health system of our country. Have you seen the medical OPD of a government tertiary care hospital at 10am? The doctor there has no time to even breathe. Patients with any kind of condition – simple/complicated are referred/self-referred to tertiary care centers necessarily/unnecessarily. This kills the efficiency of government tertiary care centers. And on the other hand, primary and secondary level centers go underutilized. Not many hospitals have the system to reject patients. I have heard NIMHANS does this. They screen, they accept/reject patients. They refer back to lower hospitals as soon as possible. This perhaps prevents NIMHANS from going crazy (pun intended). But what about other big government hospitals?

    Is this workload issue exacerbated by seniority based hierarchy?
    Yes again. Medical colleges work on the principle of infinite delegation. The Head of Unit delegates to Professor. Professor to Assistant Professor. AP to Senior Resident. Senior resident to final year PG. Final year PG to second year PG. Second year PG to First year PG. First year PG to Intern. Intern to the patient, sometimes, even.

    When the delegation culture is accepted, there is no way adding more staff helps, either. If you are a new staff and you don’t delegate, you are an idiot.

    Is ragging accepted?
    Yes. The entire system is a form of ragging. The hierarchy I just described, that is the foundation of it. That a junior is the slave to the senior is the concept that underlies the hierarchy. The sort of visible ragging that is prohibited through law is just tip of the iceberg. This visible ragging is the initiation step into the hierarchy. The catch-them-young process of making people subservient. The training phase for silent acceptance.

    If it is so bad, why does nobody speak about it?
    Can’t you see the irony of the situation? The system is designed to prevent people from asking questions. From the first day of medical college people are taught to stop thinking for themselves, to mend in like sheep, to stay low and not attract attention. (This happened to me. I was overjoyed on the first day of medical college about the fact that I am finally in a medical college and I was wearing a small smile on my face in the histology lab when attendance was being taken. One of the faculties was offended by my smile. A “helpful” old faculty suggested to me that I change my ways. Literally on day one.)

    Who do you think, trained “well” in such a system, will come out and criticize the system? Only those who could keep their spirit alive throughout, or those who could rekindle their spirit afterwards. How many of us are capable?

    Plug: Is this herd mentality also the reason why people are stuck in the race for specialization?
    You answer.