Tag: Public Health

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 really never understand what circumstances made someone choose the profession of sex work especially at the bottom of the pyramid. However, I didn’t get enough peace and thinking space for writing the review of this book. I don’t know how to express my lack of knowledge about this topic but I still know nothing about the lives of sex-workers to comment on their profession and their lives. Honestly, I am feeling perplexed because this book shows to me 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 only 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 and it’s so amazing, it compels the author and also me to put our problems in perspective and they seem very small.

Recently I was also reading this book called, “A People’s Constitution” where the author has dedicated one chapter that talks about sex, work and freedom in the Constitution. In this chapter, many women whose main livelihood is sex-work assert that this is their livelihood and they have the fundamental right to practice their profession that is guaranteed under Article 19 of the Indian Constitution. However, the author of this book-Rohit Dey also informs us 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.

How to eradicate poverty from the world?

Nothing is more dreadfully painful than poverty, and gripping poverty robs a man of the lofty nobility of his descent”- Thiruvallur

On July 10th, 2020, a six-year-old girl fell into a stormwater drain in the Marathahalli area while playing with her friends. She is the daughter of Nityananda and Boni Koli. They are migrants from Assam, living in the nearby slum area. Her father works as a security guard and mother as a domestic worker. And there has been no update on this incident till now. Who is responsible for this tragic incident? This incident shows the ‘hazards of being poor’ as also mentioned by the authors of this book. The poor people’s lives inextricably linked to huge amounts of risks not only related to income/food but also related to health, political violence, crime, and different kinds of shocks like the recently declared lock down amid the covid-19 pandemic.

This book has always been part of my reading list but when both the authors of this book won the Nobel prize last year, I decided that I have to finish this book soon. The curiosity and the zeal to find solutions how to eradicate poverty and why they do whatever they do in their lives and why policies world over fail to bring about a substantial difference in their lives, has always intrigued me.

“Poverty leads to an intolerable waste of talent. Poverty is not just a lack of money; it is not having the capability to realize one’s full potential as a human being.”

Amartya Sen

I have always been moved by people’s lives. If I see people living in difficult circumstances, I always ask myself why life is so unfair for a few people and a bed of roses for some. And many times I felt like crying inside because I am helpless as if I can’t do anything about it. Why someone has to lose its dignity because of a lack of resources. This is inhuman. Poverty is itself so inhuman. It makes you miserable from inside and you don’t have the strength to face the world.

These are some of the pertinent questions asked by the authors in this book. Why is there still poverty in the world or India? Why well thought out policies of the government of India have been failing to eradicate poverty for a long time? Why does no one ask the poor about their choices, their priorities, and why they are making the choices what are they making? It is absolutely necessary to understand the reasons behind their choices/decisions in life to frame better policies for eradicating poverty?

It’s not that the world has not tried to eradicate poverty. However, there are different ideologies/views present in the world to solve the problem of poverty. Jeffrey Sachs in his book, “The End of Poverty” says that ‘foreign aid’ is the key. Even aid establishment institutions like the United Nations and the World Health Organization believe in spending money on aid. William Easterly, Dambisa Moyo & others are not in favor of providing aid as they both argue that aid does more harm than good. They believe that we should respect people’s freedom if they don’t want anything, there is no point in forcing it upon them. Darren Acemoglu & James A Robinson’s theory of institutions given in his famous book-“Why Nations Fail”, believes in a fundamental change of the institutions to bring about any positive change in the country. However, there is hardly any focus on understanding the choices of the people and why they do what they do.

Mostly we judge poor people about the choices they make in their lives. Why don’t they save enough for them for the difficult period? Why do they produce many kids if they can’t afford a better life for them? Why don’t they take benefits of the government schemes? Why poor people don’t want health insurance? Do the poor really have a choice to control their fertility decisions? Why children of the poor don’t learn anything despite going to schools? Why don’t they get enough nutrients?

The authors had made it clear that there is really no difference between the decision-making of the poor and other people because they are also normal human beings. They also have the same problems of temptations, lack of self-control, weak beliefs, procrastination, and the problem of ‘time inconsistency’. Through various surveys, interviews and other evidence, the authors have shown that somehow the whole system is designed or exists in a way that makes it really impossible for the poor to come out of the vicious circle of poverty. For instance, they don’t have access to formal banking institutions and if they have, they have to pay higher interest rates, they don’t have any fallback option in the condition of shocks like demonetization or the recent lockdown, poor children are not wanted in schools unless they show some exceptional capabilities and also forced to drop out, they don’t have faith in the public health system because of the combination of beliefs as well as psychological sunk cost effect. And because of all these things, the poor may become skeptical about supposed opportunities and the possibility of any radical change in their lives, and also since they suffer from low depression, they lack the capacity to make sound decisions. And the vicious circle continues.

However, it’s not all doomsday scenario as the authors have also provided ways that can be used to bring about substantial change in the lives of the people. The fundamental argument of the authors is that ‘it is not always necessary to fundamentally change the institutions to bring about any positive difference rather change can also happen at the margin.’ According to the authors, though they didn’t find any magic bullet, they certainly found out few ways to improve the lives of the poor:

  1. Poor lack of credible information. So there is a need for innovative, credible, and simple information campaigns to make people aware of various schemes and their benefits and also their rights.
  2. Use the default options and nudges to enforce positive behaviors as they don’t have enough time & resources to think about themselves to make decisions.
  3. There are reasons like moral hazards, adverse selection, and lack of self-control that prevent markets to exist for the poor.
  4. Policies are failed in poor countries because of three Is-Ideology, Inertia and Ignorance and there is a need to realize the fact that change can also happen at the margin.
  5. There is a need to change the expectations of people. There was evidence that when villagers in remote areas of Karnataka got to know that girls can get jobs if they are skilled in computers, they started sending their girls to school.

Not only this, micro-credit, better education for their children, good jobs, insurance against health & weather disasters, social safety-net and minimum income support can help the poor to get out of the trap. And these small initiatives will bring a little bit of hope and comfort in their lives which will give them strength and courage to think about their future. However, as even authors of this book agree that there is a lot more to know and understand regarding the lives of people. Despite that in only 273 pages, the authors have talked about all the basic problems that keep the poor in the vicious circle and what can be done and how we should not reduce all the problems to the same set of general principles. The time has come to listen the poor and the understand the logic of their choices.

What matters in the End?

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

Recently, in a small 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 and something bad. We all want to live in a fantasy and don’t want to think or realize that we all have limited time. And 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 medicine and medical system have failed to understand how to deal with a finite life and make final years a joyful experience than torturous days of your life. And how do we forget the inevitability of death and the fleeting nature of life? And 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 shows through his various interview of patients suffering from a terminal illness that how the medical system has failed to educate the medical professionals about aging, frailty, or dying. And how to inform or educate a patient about his condition? How the whole process unfolds and how does it make an impact the people around them?

I remember even I didn’t understand the value of death, and what does death means to me till someone close died in my family. The problem with us as a society is that we teach everyone, not so important things – earn a lot of money, build a big house, clear all damn exams existing in the world by memorizing all formulas, cram an entire dictionary for that GRE examination and also prepare to go abroad and earn a shit load of money. But no one teaches us how we should live our lives. What is the meaning of death? And especially, when we become old, we don’t know what we are fighting for. What are our priorities? What are the trade-offs we are willing to make? We don’t discuss what are our fears/hope for the future. What are we willing to sacrifice? What are we willing to lose, and what are we not willing to lose?

How care of the elderly changed from ‘multi-generational systems support’ provided by the family to institutionalized nursing homes in our times. Modern nursing homes act as prisons. The Elderly don’t feel good in these homes. They feel restricted, chained and their health gets worse in these nursing homes. Old people living here always felt the longing for being at home where they can have their privacy and the ‘purpose of living’ in their everyday life.

We are so engrossed in living this life that we forgot to ask the question what’s the purpose of our lives? Did we ever ask this question to us? What makes life worth living when we will become old and frail 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 the 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

Old age only brings some slowness and calmness in our lives. People in old age focus on being rather than doing and they live in a 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 both young or old generation 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” reduced the death rate. Harvard Philosopher Josiah Royce in his book, “The Philosophy of Loyalty,” inform 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 focused on the well-being of the people, rather they focused on health. They concentrated on repair/maintenance of our body parts and not the nurturing of the human soul. Not only medical field but the 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 simply being rather than doing.

Amid this pandemic, there is a need to remember our old traditions of the ‘art of dying’ and accept the death and decline as normal and eternal truth. Also, be ready to accept our lives in old age that will come along with sickness, frailty, isolation and we will need the support and care of others. We should rather not spend the last days of our life in ICU and spend it with our family members. In just 263 pages, the author has said a lot of things about life and death and most importantly how medical science/field can correct the wrong committed till today not accepting the inevitability of old age and death. Acceptance will lead to finding solutions that can make old people’s lives better and joyful in their last days.

Covid-19 crisis is an opportunity for India

This is the 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. 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 still spends less than 2 % of GDP on health when it has 18% of the world’s population. Not only the country gave health a low priority but also other stakeholders in terms of 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.Not only this HDI 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. The largest number of malnutrition children are found in India.

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 priority politically, economically and socially.

Politically, ‘right to health’ needs to be recognized as the fundamental right through an act of parliament. Some of India states have better healthcare indicators. Heath is a state subject under the Constitution of India. Therefore, best practices from these 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 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,sanitation, and hygiene needs to increase in our country. Maintaining hygiene and cleanliness should be declared as ‘issue of national importance’. People should also vote for those representatives who give importance to the issues of education, health, employment, etc.

This is 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.