Public Health – Policy Wise

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:

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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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. There has been no update on this incident as of now. Who is responsible for this tragic incident? This incident shows the ‘hazards of being poor’ as also mentioned in the 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:

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.
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.
There are reasons like moral hazards, adverse selection, and lack of self-control that prevent markets to exist for the poor.
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.
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. The authors 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.

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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.

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.

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