Monday, January 9, 2017

NEET: How do you test ethics?

As a trained medical doctor, I feel that I must say something about the recently passed legislation called National Eligibility cum Entrance Test (NEET) which will henceforth guide admission in Indian medical colleges.

It replaces the multiple tests conducted by multiple institutions and State governments with widely differing syllabi. Prima facie, this is a great thing as students don't have to study multiple syllabi and appear for multiple exams back to back and some even happening on the same day.  However, there are disadvantages too, as I have discovered by virtue of being associated with the governance of one of the Christian Medical Colleges in the country. The issue with NEET or for that matter the JEE for the IITs is that they test for pure academic merit and nothing else. Academic merit can be accumulated by enrolling in cram centers like Kota whose sole reason for existence is to produce students who can enter those hallowed gates.

However, coming to the Christian Medical Colleges, till the time they were allowed to conduct their own exams they did not only look at academic merit. In keeping with their ethos, they looked for (not always successfully of course) those who had the aptitude to go and serve in rural India, the purpose for which these medical colleges were set up in the first place. There is also another Gandhian philosophy based medical college, which similarly looked for ethics and values in their students and not just marks.

A recent NDTV sting operation brought out the horrendous fact that in Punjab many medical colleges function with the help of hired 'ghost' faculty, private practitioners hired for 2-3 days simply to help get the college its license. Now imagine being treated by doctors who are not qualified, because they went to a college that operated with this kind of faculty. After all, when we seek out a doctor for treatment, we do not typically ask which college and university they passed out from.

In professions like medicine and many others, it is simply not enough to grade a student by how many marks he or she scored. There is such a thing in medicine as the Hippocratic Oath (and equivalent honour codes in other professions).  If we only evaluate students for their academic merit without any look at their motivation, character and ethics, which we subsequently expect them to abide by, then something is surely amiss.

Sunday, January 8, 2017

Dementia - When the mind fades away

As per the estimates of the World Health Organization, the number of aging population is increasing in countries like India and dementia is going to become an epidemic among the elderly in the coming decades. Although so far, I have not known anyone personally who is or has suffered from dementia, I am aware of people in my circle of friends who have. Since dementia is generally speaking, largely seen among senior citizens and there are in my immediate and extended family (and I myself am crawling in that direction too), I though to educating myself on the subject a bit and recently did an online course on dementia.

The course with videos of patients and care givers themselves describing their slow and steady downward sided into the disease with some of those videoed showing fairly advanced symptoms and the care givers describing the stress and strain of providing care in a context that can last for several years left me quite disturbed. Looking up the recent statistics, I find that over four million Indians above 60 have the condition, which is around 3.7 percent of that population. Approximately, one out of every 16 households with an elder has someone with dementia. Yet as I look around and ask around dementia remains a neglected area in healthcare, and many families do not seek or get suitable diagnosis or treatment for dementia symptoms. Poor awareness about dementia means that elders who experience problems like forgetfulness, confusion, or difficulty doing tasks do not consult doctors. 

India also struggles with cultural obstacles to improving care for those suffering from dementia. Institutional treatment is considered a taboo in India, as children do not want to be seen as abandoning their aging parents. Many even want to conceal the fact that their parents are suffering from dementia, at times preventing the patients — and the families — from getting the care they need. Myths, superstitions and misconceptions thrive and abound and erect further barriers in addition to the ones already existing due to inadequate public health infrastructure and largely unaffordable private mechanisms of care. The course that I did left me disturbed for one particular reason. The course was designed in the UK where through the NHS and existing support groups, there exists a reasonable structure of care and even there the care givers as they gave their interviews appeared fatigued and worn out and at least one spoke of having to give up their career because the full care giving routine, would not allow for a regular job. I do not what it is like for Indian care givers with far less support and a lot of stigma and what they go through. Clearly Dementia is a condition which is probably more a social problem as much as a medical one and needs attention from that lens.

Saturday, January 7, 2017

Security Guards : Exploited Labour in the National Capital

A few weeks ago, I was staying in a nearly empty guest house with just a security guard (also doubling up as a part time housekeeper) for company. For the two or three days that I was there, he took care of me well. As I was about to leave and my taxi was at the gate, he asked if he could have a few minutes with me. He asked me if I was a doctor as he had heard. When I affirmed that I was, he rolled up his trousers, exposing an angry, swollen and very obviously infected wound below his right knee, he asked if I would prescribe him something. He told me that he was applying some ointment locally but it wasn’t working. The condition of the wound was such that it was very clearly not going to heal through application of any local ointment.

Antibiotics and possibly strong ones at that were needed, if not some minor surgical intervention to drain the pus. Not wanting to prescribe anything in a hurry, I asked him to visit a doctor knowing that the Delhi government had recently opened Mohalla clinics which were said to be functioning well. He told me that wasn’t going to be possible. On probing further, he informed me to my horror that he received a monthly salary of Rs 6,000 with no leave for a 12 hour shift , 365 days a year and if he took any leave at all due to dire necessity, he would lose a day’s wages and with his pay being what it was, he couldn’t afford that. All I could do with my taxi honking impatiently was to give him my phone number and ask him to call me the next day so that I could take a little more in depth history, if I needed to prescribe anything. He never called back, I have never returned to the guest house since and I often wonder how he is faring.

The security business in Delhi has been operating under the Delhi Private Security Agencies (Regulation) Rules, 2009. Under this Act, a security agency takes a licence for its operations, which remains valid for five years. Most of these companies have been flagrantly violating the rules and regulations of the PSARA guidelines. Week offs, insurance, perks are a far-fetched dream for these guards hired on contractual basis. Many of these guards are not even acquainted with the rights and duties made for them under the above mentioned guidelines. They have been working for the sake of getting employment which is still a dream for many, thus, encouraging agencies to hire people on wages less than the stipulated amount.

Delhi is now being governed by a government that is of and for the “Aam Aadmi” and it is time the government took note of the pathetic conditions under which security guards work. Just as ministers are busy inspecting schools and hospitals and penalizing them if they are not meeting their obligations to the poor, it is time that some one picked up the cause of these exploited security guards.

Tuberculosis : An Under reported killer

Many years ago, while visiting a village called Arogyavaram in Chitoor district of Andhra Pradesh which hosts a Christian Mission Hospital, I was shown a cottage where Kamala Nehru, the wife of Jaaharlal Nehru had once stayed decades ago. At that time, Arogyavaram a place with a salubrious climate was a TB sanatorium and Kamala Nehru a patient hoping to recover her health there.  In those days, (we are talking of the period around 1930), TB had no cure and the only treatment prescribed was a longish stay in a TB Sanatorium where it was hoped that a benevolent climate and good nutrition would aid recovery. That didn’t happen to Kamala Nehru however and she moved from sanatorium to sanatorium eventually dying in one in Lausanne in Switzerland in 1936. Exactly a decade later, Streptomycin, the first drug to be effective against TB was discovered.
Tuberculosis has been with since antiquity and has always carried with it a lot of baggage and stigma. India has its share of the disease burden with about 3 million people suffering from it at any given time and is the country’s largest public health challenge. It was a challenge in itself and then in the 1990s and beyond with the spread of HIV & AIDS, and the close association with TB in immune compromised people, it became a bigger challenge.

A bigger challenge though, which multiple advances in medicine since the discovery of Streptomycin, all those decades ago, is the fact that the duration of treatment is long( six months onwards) and many of the patients drop of the treatment radar along the way. This incomplete treatment regime has given rise to strains of multi drug resistant TB. India again has the dubious distinction of having the second largest number of drug resistant TB cases after China. The problem is not going away anytime soon.

A larger question, is the data that I have cited even correct?  According to a report published in the prestigious journal ” Lancet”, more than a million tuberculosis (TB) cases may be missing from official statistics in India as many cases go unreported and the data only captures the numbers of people reporting to health care facilities in the organized sector. But because of factors that are both economic as well as social, many patients seeking treatment for TB turn to unregulated private doctors who often do not report cases. It is also difficult to track as to how many of such people actually complete the course of treatment. Again, one has to fall back on estimates and they seem to indicate that Out of the 2.7 million individuals with tuberculosis (TB) in India in 2013, estimates show that only about 1.05 million or 39 per cent completed therapy through the government TB programme and survived for one year after treatment without experiencing a relapse, according to a report published in the Indian Express. In today’s infrastructure driven age, public health does not attract too many eyeballs. Yet TB, where India hosts the largest number of patients, has an under noticed and under reported problem on its hands. 

Tuesday, December 2, 2014

Medical Missions in today's time and age ...........


A couple of decades ago , a debate on the essence of medical missions today would not have been necessary. Medical missions meant mission hospitals which were mini townships, often in the middle of the wilderness, sometimes standing with a school and almost always a church. Medical missions has a history in India going back to the Colonial era because it is one of the earliest and most visible manifestation of missions that was visible and still is visible to the common man. It was widely promoted by the then government and can be understood in my view as one of the earliest manifestations of public private partnership. The state often leased out land to the Mission and provided facilities so that drugs and equipment could be brought into the country and in return the missionaries provided medical care with personnel that they brought in. the arrangement worked well at a time when government provided medical care did not extend  beyond  the big cities and hospitals were usually attached to medical colleges or cantonments and in the princely states was dependent on the benevolence of the Nawabs or Rajas in place.  Three developments challenged this cozy arrangement.

The first was the advent of independence and the foundation of the welfare state where the State assumed the responsibility of providing health care (among other facilities) to its citizens as part of the Nehruvian vision. This meant the inauguration of the Primary Health care infrastructure throughout the length and breadth of the country. How effective this vast mechanism was is another question, but for the first time, outside the big towns and cities, a systemic alternative to mission hospitals became available and mission hospitals lost their monopoly. The quality of care at the PHC and associated district hospitals might or might not be great, depending on who manned them but an option to Mission Hospitals had emerged. Also post-independence, the involvement of missions decreased over time as the symbiotic relationship with the Colonial government and a natural chemistry was missing with the new post-independence government.  More on this later

The second big challenge happened in 1983 when Apollo Hospitals opened up in the county and began corporatizing health care with the clear aim of providing clinical services with an eye on the bottom line and increasing shareholder value.  The latter did not necessarily make health care cheaper by default, but it did spark of innovations in health care at the business model level and not just at the clinical level. Till this time, health care in the private sector was at least notionally nonprofit. Health care in the private sector was not usually cheap, but the “profits” were usually ploughed back into the facility, to facilitate research, improve infrastructure and so on. For the first time, a hospital was opening whose sole reason to exist was to earn profits for its owners. Although there were nay sayers, even in the pre-1991 pre liberalization era, the hospital came to be and eventually spawned a whole range of corporate hospitals – big and small.  Now before the advent of the corporate hospitals, there were the mission hospitals and there were a few large nonprofits. Mission Hospitals would treat rich and poor alike and the rich had few options at the time. Along the way, the rich would cross subsidize the poor patients in the Mission hospitals but with the coming of Apollo and others accompanied by aggressive marketing, the rich had more options to choose from.

The third was the entry into India of medical insurance. Although less than 15 percent of India is insured, the entry of health insurance rewrote all or many of the ways in which health care had been practiced hitherto. To rationalize and reduce payments against premiums, treatment protocols began to be rationalized, hospitals began to be graded and tie ups between insurance companies and hospitals began to happen.  As more and more insurance companies set up shop, they brought in practices and norms that one had to adhere to or be outside the mainstream medical system over time.  A limited few medical hospitals adapted and thrived , a lot many simply stayed put and gradually began to get obsolete. It is then that the debate on revisiting medical missions perhaps really started – when mission  hospitals began to be financially less and less viable and the question became very real – how else could medical professionals live out the gospel if the only model in which it had been practiced had become something that could not anymore be practiced ?  

to be continued.........

Saturday, July 10, 2010

Why do men drink so much ?

Recently while on a visit to our program in the slums of Chennai, i noticed that all our programs were structured around women. The program was a very successful one and the team had worked hard with the slum community as well as the local slum clearance board to make thinngs happen and very visibly, the impact was there for all to see. But no men. Of course it was day time and men might be at work; but still I asked. Any programs with men ? No. why ? Some whispers and murmurs, but no answers forthcoming. But curious , i keep probing. In a way, i know what the answer will be, over the years, I have worked with many slum communities and the work is always or almost always with women. So the answer , when it does come, does not surprise me. We do not have any program with the men in the slums because they are either at work or if not , they are drunk.

so why do men drink, I ask ? Well, another round of familiar answers follow. Men go to work and get tired and need a drink for recreation. Oh, they have lots of worries and tensions and alcohol helps them forget their worries and tensions for that period of time when they are drunk. And so they drink. I probe further – what do women do and why don't they drink ? Well, women don't go to work and are not involved in manual labor , so they do not have the compulsions that men have. But they do have their worries and fears don't they ? Oh, yes, I am told- the women have their own fears and worries. So what do they do ? .... well they throw the household utensils around and then go to the neighbour's house to gossip. So in the evening , all the slum women are huddled around gossiping , while the men are slumbering, dead drunk. Neat. Very neat.

For years, i have been observing programs planned with men almost always fail, despite the same dedicated staff, the same meticulous planning and the same effort put in. programs with women succeed; programs with men fail; and usually because nothing consistent can be planned with the menl because of this alcoholism problem among men in the slums. This is case with us in Oasis, it is often the case else where too. Alcohol seems to be the almost universal sopoforic of recreation in the slums and almost the only one it would seem. So can any thing be done for men or are all developmental programs in the slums destined to succeed with women ?

some thing about Oasis's programs among young men gives me a ray of hope. I don't know where we will ever be able to break the scourge of alcohol and its hold among rhe older men, although I should not be pessimistic. But our program with the young men form the slums and others on the verge of dropping out of society which focuses on sports as a tool might be the answer, at least for the younger people. Using football as a glue, Oasis is able to bring together young men who might all have gone their own separate and destructive ways. These young men learn the value and worth of discipline, sportsmanship, fairness and respect for rules and perhaps most importantly make lasting friendships and bondings that may, if they are lucky , last a life time.

The Oasis progam is only a few years old and it could be said that in many ways, it is in its infancy. There is very certainly a long way to ago, and it will be a long time , before we can draw any definitive conclusions. Perhaps , I am being a fool to anticipate so much , expect so much to happen from a program that is so new , so nascent. But even so..I dream that way. I dream that one day it will be possible to walk into a slum and ask the question – not “ why do men drink so much ?” but on the contrary “ why do men play so much ? ”. it will be the day when the brawls caused by drink wll be replaced by the laughter and the banter of sport. That would be change. That would be transformation. That would indeed be life.

Bored meetings or Board Meetings

My organization's Board meeting took place on Saturday. Though the meeting was planned as a whole day event, all business had been conducted by lunch time. There were several eminent people present, all spoke and shared their views articulately and freely. Yet it was still possible to have a vibrant discussion and still all the transactions could be completed earlier than what was anticipated. Every one found time to listen to each other and although by the end of the meeting, a lot of decisions had been, they had been made so collaboratively that it would be very difficult for any one person to have claimed credit for the decision.

The free afternoon time left with lots of time to think of other Board meetings where I have participated, usually as a member, but sometimes as a participant. I remembered meetings of different hues; but the most common memory is that of dull, listless meetings dominated by one person, usually a man, while others sat around with a bored look, wondering what they were really doing there. Some basic, legal requirements were hurriedly gone through monotonously and then the crowd quickly dispersed. They would gather together in a similar fashion in another 6 months or a year for a repetition of this mindless ritual.

Sadly, governance in India is not taken that seriously; at least not in the nonprofit sector where I have spent a lot of my life. It is assumed that because the organizations involved in charity work, are supposedly there with highly altruistic motives, everything is just fine with the way they are run and with the way they are governed. And so Boards and such, by whatever name called, are considered a necessary evil, thrust upon us by the nasty arm of the law. Governance thus is something that is considered an intrusion demanded and required by the law and not something to be pursued for its own intrinsic merit. And so a lot of boards and governing bodies are filled by sycophants and toadies- hangers on with nothing of worth to contribute. The worst case scenario – and yet not uncommon either, are boards staffed by family members and relatives of the founder or the CEO.

This of course is a pity. My own board meeting has impressed upon me the value of having caring, involved people of integrity on the Board. They perform all the necessary statutory duties of course; but go far beyond that limited statutory duty. By virtue of the eminence they have in different fields of occupation, they become helpful sources of information, guidance and most importantly – of advice. They do not intrude in the day to day running of the organization – an activity for which they are too busy any way; but remain available to advise, guide and provide valuable insights – something that only the foolish would overlook.

Although it would see that governance can fall by the way side even in the corporate sector as evidenced by the experience of Satyam, it is an unfortunate fact that in the NGO sector, we do not know enough to educate our board members on what their individual roles and responsibilities are and what they can and cannot do. The sad result is that often NGO boards are either complete rubber stamps nodding assent to everything that the Chief Executive does or at the other extreme, an over bearing, micro managing body, stifling every initiative.

Perhaps , the trick is in having the right composition for your Board. In choosing people, who are eminent in their profession and are also adequately informed about the work of the organization. Individuals, who are committed without being too interfering or intimidating. When a bunch of such people gathers, animated conversation crystallizes into sagely counsel and wise decisions. And Board meetings are no longer bored meetings.