Category: Public Health

How to get things right?

Checklists seem able to defend anyone, even the experienced against failure in many more tasks than we realized. They provide a kind of cognitive net. They catch mental flaws inherent in all of us-flaws of memory, attention and thoroughness.”

Excerpt from the Book

It’s been more than two years since I started making a to-do list every day. And I am still doing it. It not only helped me plan my day but also made me efficient. The question here is whether a simple to-do list would be really helpful in getting things right. The book I am going to discuss says so. In fact, I was a little skeptical, thinking that it’s more than obvious that a to-do list works; why would someone write a book on it? But this book really makes sense by taking the reader through the evolution of checklists.

To err is to be human. We have all heard this multiple times. In fact, it has been estimated that one of the greatest contributors to accidents is human error in any industry. Perrow found that, on average, 60–80 percent of accidents involve human error. Errors in some fields can be overlooked but not every profession can take the risk of even making a tiny error or overlooking the smallest step. Because a small error in the medical field will cost someone their life. In today’s newspaper, I saw this story where a woman was given blood from the wrong group, leading to the deterioration of her health. How grave is this error? There can never be any justification for it. A small error led to the failure of India’s Chandrayan-2 mission, as we all remember.

Do we know how we can make things right? Do we have the capability and capacity to make things right all the time? How do we deal with extreme complexity of the modern world? Why do we make small errors, and how can we avoid them? Is it possible to be 100% accurate?

Atul Gwanade, a professor of surgery at Harvard Medical School, suggests in his book titled ‘The Checklist Manifesto’ the simplest solution anyone can think of. A checklist can help us manage the extreme complexity of the modern world. A detailed checklist acts as protection against the failure of the human mind, memory, and attention. It increases the success rate. According to him, failure results not so much from ignorance (not knowing enough about what works) as from ineptitude (not properly applying what we know works). That’s where a simple checklist comes into picture.

So, the important question we need to ask here is : why should a common person be aware of this method of checklist? It’s because this is not only useful in the medical field but also in other activities that are sometimes mundane and repetitive but also crucial not to be overlooked. The author provides examples of checklist successes in other diverse fields, such as aviation, investment banking, skyscraper construction, and businesses of all kinds.

The author differentiates between good and bad checklists too.

The author mentions three characteristics that are part of the code of conduct of any profession, the expectation of selflessness, skill and trust-worthiness along with discipline. Discipline is the hardest to develop because human beings are by nature flawed and inconstant creatures. And checklists can help inculcating discipline in the people, adds Gawande.

In the end, he also urges the users to keep refining these checklists to make them work as per changing circumstances and time.

In an age of unremitting technological complexity, where the most basic steps are too easy to overlook and where overlooking even one step can have irremediable consequences, something as primitive as writing down a to-do list to “get the stupid stuff right” can make a profound difference.

Do you create a checklist for anything in your personal or professional life? If yes, do let me know in the comment box. Also, if you liked reading this post and gained something from it, please buy me a coffee by clicking the link below:

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India’s First Women in Medicine

In Picture ( Anandibai Joshi, Kadambini Ganguly, Muthulakshmi Reddy, Rukmabai Raut, Mary Poonam Lukose, Haimabati Sen)

“If this life is so transitory like a rose in bloom, why should one depend upon another? Everyone must not ride on another’s shoulders, but walk on his own feet” – Anandibai Joshi

Kavitha Rao’s book, “Lady Doctors: The Untold Stories of India’s First Women in Medicine,” tells the stories of six inspirational women who defied all the rules of society and built a career in medicine while also contributing to women’s emancipation. Although these women were from different parts of the country, they were united by their desire to achieve freedom and respect in their lives. They built institutions and advocated for women’s rights through protests and petitions. 

  • Anandibai Joshi: the first Indian woman with a western medical degree. Tragically, she died before she could practice medicine.
  • Kadambini Ganguly: the first Indian woman to practice medicine; she was branded as a whore by a conservative paper at that time. She was one of the first women to speak at the conference of the Indian National Congress (INC). A mother of eight children, she died in the course of her duties as a doctor.
  • Rukmabai Raut: a fiery woman who left a child marriage, shattering all patriarchal rules. Following her service in dealing with the deadly plague in Surat, she received the Kaiser-i-Hind medal in 1898.
  • Haimabati Sen: a child widow. Defying all Hindu tradition, she remarried and became a doctor.
  • Muthulakshmi Reddy: First woman to be elected vice-president of a legislature. She was instrumental in realizing the goal of the universal franchise for women, raising the marriage age, and abolishing the devadasi system.
  • Mary Poonam Lukose: the first Indian woman to be appointed to a legislature. She was instrumental in building Kerala’s public health care system.

You must read this book to learn about the achievements of these inspiring women whose stories are nowhere seen in our history textbooks. Please let me know your thoughts about this book if you have already read it.

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A Story of Courage & Hope

Far, far away, someone was weeping, but the world was sleeping, any dream will do.

Andrew lloyd Webber & Timothy Rice

“No women wants to get into sex work. It’s not that they made a choice, but rather that they had no choice to make. Their life is tough but sex workers so often just to live to create a better future for their kids. It is the single overriding reason why they carry on.”

Excerpt from the Book

I read this book last year and it hit me quite hard. We can never understand what circumstances makes someone choose the profession of sex work especially for the people who are at the bottom of the pyramid. However, I didn’t get enough peace and thinking space for writing the review of this book. I know nothing about the life of sex-workers to comment on their profession. Honestly, I am feeling perplexed because this book shows that they are doing sex work out of desperation and poverty. A woman is forced to sell her body for fifty rupees or even for a meal or some milk for their infant. Thinking of this situation makes me sad and empty. Still, these people despite facing struggles and problems in their lives, show us the courage, resilience, strength, hope, and optimism towards life.

Recently I also read this book called, “A People’s Constitution” where the author has dedicated one whole chapter that talks about sex-work and freedom in the Constitution. In this chapter, many women sex-workers assert that this is their livelihood and they have the fundamental right to practice their profession guaranteed under Article 19 of the Indian Constitution. However, the author of this book-Rohit Dey also informed that the term ‘prostitution’ in India was entirely a creation of colonial law.

As the author of this book shows that there were many myths and misconceptions about sex work in India. There were absolute denial, apathy and stigma towards the idea of sex and sexuality. As per one survey, about five women in every thousand involved in sex work.

This book gives you practical lessons about public health and dealing with people and the community when they are in the most vulnerable and desperate situations. This book makes you realize how public health can be delivered through successful community participation. The role of people is very important in dealing with any virus. And we can see even during this current pandemic, the prevention of this virus is dependent on people’s following of some basic rules. And when people have the ownership and they are engaged in dealing with the problem, they will come up with innovative solutions.

As the author shows the successful role of the community in the Sonagachi area in Kolkata. And the best thing is that they have organised themselves to deliver services safely, addressing the root cause of their vulnerability and also emerged as prime agents of change. They have created their own association named Durbar Mahila Samanwaya Cooperative (DMSC) which has three parts: Service provision including clinics, a cooperative bank, and a cultural wing. And this association is also quite vocal about recognition of sex work as an occupation and preserving & protecting their occupational rights asserting that it’s their fundamental rights.

However, there are some revelations in the book: For instance, brothel sex is very minimal in the country. In fact, it is dominated by street-based sex work and also practiced in homes by middle-class women to keep their houses running and sometimes for funding the education of their kids. The author also talks about ‘Devadasi tradition’ and also met various Devadasis who practice sex-work. As the author finds out during his travel to these places and speaking to affected women, the Devadasi tradition has become a front for impoverished parents to get their young daughters into sex work. In fact, as per the Policy Brief on Devadasi legislations published by CLPR, shows that poverty, caste domination, patriarchy & religion are the main causes for the Devdasi system to still flourish.

The best thing mentioned in this book about the Avahan mission led by the author Ashok Alexander with the support of Bill and Melinda Gates Foundation is that it made a substantial improvement in the lives of sex-workers and halted the HIV virus among the most vulnerable people in the country. The Avahan movement helped India to achieve one of the Millenium Development Goals (Goal 6-To combat HIV/AIDS). However, this achievement was never celebrated due to the stigma attached to this disease.

The most touching part of this book was narration of those stories of hope and courage. Despite all odds and facing so many challenges, these people show us how to smile even if you are in the most desperate and vulnerable situation and how not to lose hope anytime. The story of Parvati ( an acid attack victim & also a sex worker), Kamla (who was raped by five men), Danny (got infected to HIV in his mother’s womb), Kavita( a sex-worker from Shimoga who later on became part of Avahan and Ashodaya), Shahid ( a HIV positive who later on became director of program for Ashodaya) and many others are stories of hope and courage. Our lives look so easy and comfortable as compared to their lives and even after this, we crib about many things but they are struggling and smiling and spending each day living a life of dignity in so much adversity.

And in the end, you have nothing but these moving & memorable stories to think about and remember.

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What matters in the End?

“Death is inevitable; Each moment is precious; Nothing matters in the End”

Recently, in a light conversation, I said, “We all are going to die” in the context of this dreaded pandemic. I could see the expression of people disliking that comment because no one wants to talk about death in our society. Death is seen as inauspicious. We all want to live in a fantasy and don’t want to think that we all have limited time. This thinking has repercussions not only on our health but also on our future. As the author says, “how we seek to spend our time may depend on how much time we perceive you will live forever.”

This book is actually about the experience of death and how the medical system has failed to understand what it means to deal with a finite life and make the final years a joyful experience. Do we forget the inevitability of death and the fleeting nature of life? When we become old, we don’t want to talk about death, we talk about living.

The beauty of this book is that it has been written by a surgeon who is also a professor at Harvard Medical School. This book has his personal accounts of dealing with terminal patients and also the death of his own father. The author has shown how the medical system has failed to educate medical professionals about aging, frailty, or dying. Gawande speaks about the failure of the medical system in informing or educating a patient about his condition? There is a need to understand the unfolding of the whole process and its impacts on people around them.

Death had no meaning to me until someone close died in my family. Society teaches people “not so important things” such as making a lot of money, buying a big house, memorizing every formula to pass every exam, and studying for the GRE. However, no one teaches us how to live our lives. What does death mean? Especially as we grow older, we have no idea what we are fighting for. What are our priorities? What are the trade-offs? We don’t talk about our worries or hopes for the future. How much are we willing to sacrifice? What are we willing to give up?

How care of the elderly has changed from ‘multi-generational systems support’ provided by the family to institutionalized nursing homes. Nursing homes today act as prisons. The elderly don’t feel comfortable in them. They feel chained and restricted. The elderly living here always yearned for privacy at home.

We are so engrossed in living this life that we forget to ask the question: what’s the purpose of our lives? Did we ever ask this question to ourselves? What makes life worth living when we will become old and unable to care for ourselves? To answer this question, the author discusses psychologist Abraham Maslow‘s influential paper, “A Theory of Human Motivation” which is depicted in the form of a pyramid and talks about the hierarchy of needs of people. According to Maslow, ‘safety’ and ‘survival’ remain the primary and fundamental goals of our life even in our old age.

Maslow’s hierarchy of needs

People in old age focus on being rather than doing and they live in ‘the present than the future. Old age generally functions at the peak of this pyramid and focuses on ‘self-actualization.’ “Living is a kind of skill. The calm and wisdom of old are achieved over time,” says the author. As per various experiments (discussed in this book by the author) conducted during some crises like the 9/11 attacks, the SARS epidemic 2003, etc., old and young both valued the bliss of life and focused on being rather than doing. This might be true for the current pandemic also. People these days from all generations are slowly realizing the meaning of life.

This book also shows the results of experiments of assisted living done on various old people where they were given small freedoms in terms of taking care of plants, spending time with a cat, a dog or a bird, etc., helped them to live a longer life. The most important finding of the experiment was “having a reason to live” which reduced the death rate. Harvard Philosopher Josiah Royce in his book, “The Philosophy of Loyalty,” informs us that people seek a cause beyond themselves. That cause could be anything: it can be small or very big. ‘We all require devotion to something more than ourselves for our lives to be endurable.’

The only way death is not meaningless is to see yourself as part of something greater: a family, a community, a society. If you don’t, mortality is only a horror. But if you do, it is not.

Josiah Royce(The Philosophy of Loyalty)

The biggest problem in the medical sector is that they never focus on the well-being of the people, rather they focus on physical health. They are hell bent on repairing the body parts and not the nurturing of the human soul. Not only the medical field but society as a whole needs to understand this, as people grow old and become aware of their fleeting life, they are more interested in writing the story of their lives and believe in living in the moment.

Amid this pandemic, there is a need to remember our old traditions of the ‘art of dying and accept death and decline as normal and eternal truth. We must accept our lives of old age that will come along with sickness, frailty, and isolation. Ultimately, we will need the support and care of others. We would rather spend the last days of our lives with our family members than in ICU. In a nutshell, Gawande has made several important points about life and death, especially how medical science can correct the wrongs committed till today in failing to accept the inevitable. Acceptance will lead to find solutions that can make old people’s lives better and joyful in their last days.

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Covid-19 crisis is an opportunity for India

A time of crisis is not just a time of anxiety and worry. It gives a chance, an opportunity, to choose well or to choose badly- Desmond Tutu
Image Credit: https://bit.ly/3xJ1dAC

This is 4th day of the lock down. Prime Minister Narendra Modi has declared 21 days lock down amidst corona virus pandemic all over the country starting from March 24th, 2020. The situation is quite grim. People are panic buying and many migrant workers are stranded in different parts of the country due to the unprecedented shutdown of transportation mediums.

When I sat on my desk to write this blog, India already had more than 900 cases. I have no idea, by the time, I finish this blog, how many corona virus cases will be detected in India. As per one article, India can see 30,000 Covid-19 deaths by May 2020 and there will not be any hospital beds left by June 2020.

Health has never been a priority for a diverse, heterogeneous and poor country like India. It can be ascertained with the fact that the first National Health Policy for India came in the year 1983 after 35 years of the existence of the Indian republic. Till now, we have only three National Health Policies in place released in the year 1983, 2002 and 2017.

India spends less than 2 % of GDP on health when it has 18% of the world’s population. Not only the whole country gave health a low priority but also other stakeholders. For instance- National political parties relegated the health as a non-issue when it comes to policy priorities for the development of the country.

India has a very low HDI index and high HDI rankings over the years. India was ranked 129 out of 189 countries in the 2019 Human Development Index rankings. Health(Life-expectancy at Birth) is one of the three dimensions to decide HDI rankings. HDI ranking has stagnated in recent years despite India being the fastest growing economy of the world.

The primary health care infrastructure of the country is in shambles due to lack of financing and acute shortage of medical personnel. 65% of health expenditure is out of pocket and some 57 million people are sent to poverty every year due to this expenditure. India has a severe shortage of trained medical professionals. As per the Economic Survey 2019-20, the doctor-population ratio is 1:1456 against the WHO recommendation of 1:1000. India has the largest number of malnutrition children.

The substandard performance of India’s healthcare system is out in the public amidst the corona virus outbreak. However, this crisis is an opportunity for India to make India’s healthcare system best in the world. Systematic overhauling of health infrastructure is the need of the hour. Heath as an issue needs to be prioritized. It needs to become a matter of great importance politically, economically and socially.

Politically, ‘right to health’ needs to be recognized as the fundamental right through an act of parliament. Some of India’s states have better healthcare indicators. Heath is a state subject under the Constitution of India. Best practices from different states need to be replicated across India. Panchayati Raj Institutions can play a major role in providing leadership to deal with any health crisis.

Economically, health expenditure to India’s GDP should reflect the proportion of the population living in India. The current expenditure is inadequate. The government of India must increase its expenditure at least by 5 % of its GDP from this year itself. Other measures like public-private partnership, increasing health insurance penetration etc should go on simultaneously.

Socially, awareness towards cleanliness and sanitation needs to increase in our country. Maintaining hygiene should be declared as an ‘issue of national importance’. People should also vote for those representatives who give importance to the issues of education, health, employment, etc.

This is a high time to realize the value of health as we can see, how corona virus outbreak has affected every aspect of human lives. Health is one of the most important ingredients in ‘human development approach’ Healthy human beings can only bring overall development and growth in the world.

This corona virus pandemic is an opportunity for India to create a world- class health infrastructure, strengthen public institutions, adopt best practices from other countries, increase public health expenditure by 5 % of its GDP, and declare “right to health” as a fundamental right for the people of India.

This blog has been republished by Social Development for Communities Foundation. Please find the link here.