Body Politics

An Emerging Voice tours Europe

2010-12-02T17:06:00.000+05:30

Graduate life at Syracuse does not really give one much time to breathe or blog so the last month was a welcome change. I was selected to be an 'Emerging Voices' through an essay competition organized by the Institute of Tropical Medicine (ITM) and got to spend two weeks with them in Antwerp, Belgium attending a workshop on building our research publication and presentation capacities and presenting my essay at the ITM Colloquium. My topic was on language barriers in healthcare settings in India, something I had started writing about on this blog quite a while ago. ITM also organised for us to go to the First Global Symposium on Health Systems Research in Montreux, Switzerland. I was selected to be one of the three Emerging Voices to present our views of the symposium at the closing plenary. We spent hours trying to collate feedback, develop a critique and fit it all into a six minute Pecha Kucha style presentation. The effort paid off when we received the only standing ovation of the symposium the next day, a moment now immortalized on YouTube.

As usual my camera travelled with me although I did not use it much during the actual workshop and symposium days. Most of the shots are from our walks around Antwerp and Sunday trips to Amsterdam and Rochers de Naye.

More Health For All blogs

2010-02-21T13:22:00.002+05:30

It is heartening to see that there are now a few more blogs written by people from the Health For All movement in India. Their blogs are slowly beginning to collectively represent the different issues and arenas that health activists work in, from the challenging ground reality of providing health care in rural India to the often esoteric world of health policy.

fieldnotes by Dr. Ramani Atkuri talks about the realities of practicing medicine and doing community health work at Jan Swasthya Sahyog, a unique hospital and community health project in Chhattisgarh.

Stories on Poverty and Rural Health in India documents an attempt by Dr. Johnathan Fine, an American physician and human rights activist to probe into the structural issues that surround poverty and ill-health during his visit to Jan Swasthya Sahyog, Chhattisgarh.

dip tinking is a personal blog by Dr. Dhruv Mankad, a doctor and health activist who has done a lot of work on training community health workers.

Right To Health Care is a blog by Dr. Ravi Duggal, who has worked extensively in the area of health financing in India.

However, conspicuous by their absence are blogs by younger Indian health activists, a group who you would assume would be more comfortable with online media. It is difficult to hypothesize why this is so. Is it that the younger generation has nothing to say or is it that they are still struggling to find the language and context within which they can express themselves?

The New Anthropologist and Johnny Lever's Hospital

2010-02-12T16:47:00.000+05:30

On February 1st, I joined a UCL-BALM research unit in Chennai as a research assistant studying stigma and mental health. This transition is an exciting one for me, since it marks the beginning of my work as an anthropologist. In the introduction of his book Global Health, Mark Nichter, a public health anthropologist who has worked extensively in Tamil Nadu writes about the problems of translating his profession into Tamil and solves this difficultly by calling his discipline 'anubhav shashtra', the 'science of experience'. This is very close to my own idea of what an anthropologist does. I aim to transition from a clinician who is an expert at experiencing patients to a hospital ethnographer who is an expert in experiencing clinicians and clinical care. I hope to look critically at how knowledge and understanding is created in the clinic by different members who inhabit it. I especially hope to explore how non-English speaking patients construct an understanding of 'English Medicine'. All this will involve me look at intimately familiar environments with a fresh eye and I start this endeavor with a reference to someone else who seems to have wonderfully fresh take on the Indian hospital. Presenting the comic genius of Johnny Lever.

MFC meet at Sevagram

2010-01-13T01:18:00.018+05:30

Thanks to my recently accquired Canon EOS DIGITAL REBEL XSi I have been a happy shutterbug this month. Check out my debut photos from the annual meet of the Medico Friend Circle in Sevagram.

The Medico Friend Circle (MFC) is a group started in the 1970s that has functioned as a sort of 'intellectual critique central' of the health movement in India. Meetings are held twice a year with all members sitting on the floor in a community circle. The content can be frustratingly impractical to the new comer at times, with hardly any actionable points coming out of two days of deliberations. However old-timers will point out that this is exactly what gives MFC its appeal. It is a place where activists and health professionals who spend the rest of the year working with the practical realities of health in India can indulge in two days of networking and free for all intellectual debate on their projects and ideas. Everyone goes home the richer.

My poems on Ultra Violet

2009-11-04T15:04:00.000+05:30

Two of my poems have been featured on Ultra Violet, an Indian feminist blog. Do check them out. And do leave an nice interesting comment. I'm at the point when I need someone to be objective about my writing.

Huddled together

2009-10-31T02:45:00.001+05:30

When it rains we the kind

Get wet. Our umbrella is not

Big enough for two.

When it stops we the kind

Get sick. Our dampness is what

Causes us pneumonia.

During sickness we the kind

Get poor. The local hospital

Is not a charity.

Faced with hunger we the kind

Get mean. Our bodies curse

Our moral self.

When it rains we the mean

Remain dry.

http://www.flickr.com/photos/freemind/ / CC BY-NC-SA 2.0

Exploring health with the wind in your face

2009-10-29T09:24:00.002+05:30

My friend Varun Kumar recently got bitten by the community health bug and decided that he needs to get a better understanding about what working for health really means. Being of the adventurous sort, he has decided to go on a bike ride across the country, visiting community health organisations along the way. One of his interests is in how mobile phones, which now seem present in even the most remote hamlets, can be used for health work. His corporate background is evident in his well presented maps of the proposed journey route. You can follow him on his blog http://journeyofvarun.blogspot.com.

AlJazeera on health care in rural India

2009-09-29T02:12:00.005+05:30

I just chanced upon this video on the state of health care in rural India by Al Jazeera English. For a network which is new to covering India they have produced a remarkably balanced report. In a span of a few minutes they give us a glimpse of India's huge burden of common yet potentially deadly infectious diseases such as diarrhoea, the worry and hardships faced by poor rural patients, the ailing government health care system, the frustrations of a doctor working for low pay in a remote area, the corruption within the system, the health movement with its activists and the private medical industry which is far away from all this reality.

Kudos Al Jazeera.

Snapshots of a doctor in rural Tamil Nadu

2009-09-24T00:54:00.004+05:30

A few days ago the our health minister announced that that doctors will get better pay and 10% extra marks in competitive postgraduate entrance exams for every year spent working in a rural areas up to a maximum of 3 years. The proposal may not address to problem of the s evere shortage of healthcare personnel in rural areas completely but it is indeed welcome news.

But what does working in a rural area actually mean? I spent two years working and taking pictures at the Tribal Health Initiative in Sittilingi in the Dharmapuri district of Tamil Nadu. Here are some snapshots.

Rural Tamil Nadu is beautiful.

This is the view from the kitchen window of the cottage I stayed in while working for two years at Tribal Health Initiative in Sittilingi, Dharmapuri District, Tamil Nadu as part of my rural service. Students from St. John's Medical College in Bangalore have to spend the first two years after graduation in one of the college's 400 recognised rural bond centres or pay Rs. 3,00,000 (Rs. 6,00,000 for the current batch).

The work is rewarding.

Apart from the three doctors and a couple of technical staff Tribal Health Initiative is run exclusively by people from the local community. Here is one of our health workers the day after the birth of her son. She was delivered by fellow health workers all of whom have grown up in the villages surrounding the hospital. She had her baby in the sun when I came for morning rounds and we all shared her joy.

You might just get to live in your dream house.

I lived on the hospital campus at the edge of reserved forest land with a small stream a few metres away. My cottage had a small kitchenette, a shower and a high speed internet connection. (thanks to BSNL WLL technology). More than I could have asked for. Meals were in a common mess for all staff who stayed on campus.

You get chances to do surgery.

I learnt more in the two years I spent working with Dr. Regi and Dr. Lalitha than in all six years at college. One of the advantages of working in a rural hospital is that senior doctors have the time and patience to teach you unlike the competitive, hierarchical atmosphere of a city hospital.

You get chances to visit patients at home.

Every doctor should try this. If you visit your patients occasionally at home then you immediately understand what is making them sick and you realise that many conventional remedies are quite foolish to say the least. Practicing medicine also becomes a challenge when you realise that most patients can't read time, read labels or even begin to understand the nature of the medicines you prescribe.

You work with a dedicated, highly skilled team.

The health workers at Sittilingi are all drawn from the local villages and are predominantly from the Malavasi tribal community. I have never seen more competence and dedication. Our neonatal unit has a high success rate only because of the energy put in by our health workers in 24x7 one on one care of sick babies.

Things get scary occasionally.

A city boy like me had to get used to the occasionally enormous, allegedly poisonous spiders that used to sit nonchalantly on my cupboard door. My room was closest to the forest and a sort of immigration desk for snakes, scorpions, spiders and suchlike.

You learn about a different culture.

Living in Sittilingi meant I also saw a part of India I missed in the city. Pongal is one such amazing festival with anticipation building up for months before the actual date and the actual festivities being dissected for months thereafter.

You become family.

Being on duty 24x7 for a month at a stretch means you really get to bond with your staff. We worked, lived, ate and joked together and there was never a time when my inexperience and bad Tamil got them visibly impatient. Here they pose with the newborn of another fellow health worker they helped deliver. Their pride in their work is obvious.

Come together, right now

2009-09-14T13:27:00.008+05:30

I have just finished attending a workshop by the International People's Health University on 'Health and Equity', where for nine days we concentrated on understanding the growing difference between the health of the rich and poor, the economic and political forces that are causing this and the social movements that have arisen as a response to this. Most participants had years of experience working for health at the grassroots level and their shared stories contributed to making it the workshop a rich experience grounded in practical realities.

The course helped us link what many of us witness as local phenomena to the much more distant economic and political arena. This can be a discomforting connection at times once you realise that as an individual you are quite powerless against such distant, undemocratic institutions such as large corporations and international bodies. This was the point in the course where the answer to such an essentially political problem emerged.

In an era when economic and political decisions made by big businessmen and our politicians have a large influence on both our individual health as well as the health of the communities we belong to, the only protection against bad, corrupt decisions is community organisation. If communities come together from the street to the global level in order to monitor the decisions our leaders make, only then we can protect ourselves from the decisions that are detrimental to our health and lives.

What do I mean by community organising? This video says it much better than I ever could.

Miscarriage

2009-08-05T14:56:00.000+05:30

A curtain of rain separates
My verandah from the hospital.
On any other day a hundred
Silent patients would pass through
The OP clinic. Each of them
Allowing us doctors to listen
Feel, touch and question them.
The warmth of their fever would
Make us uncomfortably hot.

Today the air is chilled downpour wet.
Water roars in the stony river.
Five nurses, Gi and I sloshed
Through muddy puddles to witness
Our stream in full spate.
Only one desperate couple managed
To make it on the early bus.
Wanting an abortion.

Kutti Thambi Chinna Doctor

2009-07-01T23:58:00.003+05:30

He died five hours ago.
A small boy of three.
Looked so still and limp.
His family wailed.

His house is a few fields away.
His aunt works in our hospital.
He was born here.
He died at home.

He had a fever.
He vomited for three days.
His mother took him to a
Local traditional practitioner.

Our ambulance was called.
He stopped breathing before it came.
Tha held the mother.
And both were disconsolate.

His name is not tomorrow.

Poem in a car

2009-07-01T23:41:00.002+05:30

Imagine if this poem was fashionable.
And was found in a book of fashionable poems.
Read by fashionable people in fashionable cars.

Then the name of this fashion will be
Fair fashion. And it will be fashionable to be fair.

To be fair one would need to look at the paper
On which this fashionable poem was written.
And wonder whether the paper is fair as it is
fashionable.

Who cut the tree to create a fashionable poem's paper?
Whose tree was it anyway? Does she read
fashionable poems?

Who sat in the car in which the fashionable poem was read?
Should we wonder whether the car is fashionable as it is fair?

Who mined the earth to create a fashionable car's body?
Whose earth was it anyway? Was he ever in a fashionable car?

Blood toads

2009-06-18T01:42:00.002+05:30

We deliver babies here
In a spew of blood and amniotic fluid
That splashes on our feet
Seeps into our cuts and crevices
And does daily battle with immunoglobulins
Yet the worry of contracting Hep B or HIV
Does not seem to worry the blood toads
Fat amphibians of the labour cot drain hole
Whose eyes shine at the most recent surge
Of human fluid.

Will today bring a rare gush of O Negative blood?
Will it send them scampering over the floor?
Student nurses in vain set after them
Scattering carefully stacked urine sample bottles
And a patient’s husband rushes to Salem
To buy injections that cost him two months earnings.

At night the new mother dreams
Expensive Anti D Ig courses her veins
Tiny lips suckle her breast
A multitude of pale green toads
Spawn nourished on her blood
Invade the ward hungry for more
A fresh red river flows from her uterus
Which is lax in terror.
She awakes screaming.

The junior night duty nurse runs
She awakens a thin tired doctor
The patient is shifted to the labour cot
Methergine soon flows into her veins
The now contracting uterus
Pushes out a kidney tray full of blood
Half a litre of gelatinous clots
More nourishment for the blood toads.

communityhealth.in

2009-01-16T10:28:00.005+05:30

The link has been sitting demurely on the right side of this blog for quite a while but I realise that I have never actually written about communityhealth.in so far. In short, communityhealth.in is an experiment in creating an online resource on community health in India, something that is very close to my heart. Starting this January I hope to be doing a lot of talking about this project and I have created chdotin.wordpress.com for the same purpose. Do check it out.

Coming out

2008-08-10T13:05:00.011+05:30

Occasionally I write poetry. There, I finally said it. Most of it is terribly personal, vulnerable and badly written. Over the last two months however I have occasionally written something that I feel comfortable about. Both the poems below are based on my experiences here and meticulously portray life as it really is.

A short note on the label of this blog post. 'Stone River Hospital' is a literal translation of Kal Aath Aspatre as we are locally known. Below is a photo of the river which runs about 200 feet away from my room. If someone had to literally translate what I am known as in the area it will be' Stony River Little Doctor' :-)

M's Betrayal

When the skin on the bottom of your feet
Burns. Burns really red hot.
It becomes hard and black. Like
Old cracked leather.
It makes a 'tok tok tok'
Noise like a coconut shell. Dry.

Inside creamy pus waits patiently.
The doctor will soon quit tapping
the skin with his pen.
He will mumble instructions in Tamil.
Nurses will scurry. The woman will
Starve to avoid vomiting with the anaesthesia.

In the evening Dhanam Akka will
Crack open a beautiful glass ampoule.
With the deftness of experience she will
Pull ketamine into a plastic syringe.
M lies on the steel operating table
Softly moaning under her green blindfold.

Soon cold steel clasped in latex
clad fingers will pare through
dead skin. Patient pus will burst
forth and dribble into a plastic
kidney shaped tray. Raw red
flesh will make a shy debut.

Akka, will you promise not to tell
Anyone. Promise on your heart.
Promise on your head. Promise. Promise.
I didn't fall into a cooking fire
because I fainted being two months pregnant.

I took some tablets because I didn't
Want a second child right now.
Ten pills from the local doctor. They
They knocked me out and then
Then my husband came home drunk.

Promise you won't tell anyone. Promise.
On your heart. Promise on your head.
He was in a murderous rage. He.
He tied me up and then he.
He stuffed a cloth in my mouth.

---------------------------------------------------------

You might be tempted to ask why this has been the best year of my life. Here's why ....

A Rural Practitioner's Happiness

Tiny hands. Big eyes.
The cutest damn expression in the world.
That's my reward. That's happiness.

Then I walk out of the labour ward.
I can see hills all around. Green.
That's my reward. That's happiness.

My cottage sits on the edge of the forest.
Full of books, art films and insects.
That's my reward. That's happiness.

The local women who work at our hospital
Call me 'Anna'.
That's my reward. That's happiness.

An old therakoote vadiyar
Is grateful I was with him during his second MI.
That's my reward. That's happiness.

When death comes. Despair.
Loneliness and gastritis.
I think of my rewards. I try happiness.

communityhealth.in posters

2008-08-01T21:40:00.008+05:30

I had spent the whole of yesterday in the OP clinic seeing patients. Occasionally I would nip back to my room for a break and to read a little more of Helping Health Workers Learn, a book that is slowly revolutionising the way I understand community health. Inspiration struck at 1 am after reading the passage which I subsequently used in the first poster. The pictures are from my travels over the last year.

Click on the poster to enlarge.

The second poster is more personal. It was a sort of artistic representation of what being a community health activist at 1 am at night feels like. It uses a lots of ideas about art that I have been slowly developing such as where the artist situates himself, the progression of time between the pictures (look at the guava) and creating different messages depending on the distance between the viewer and the poster among others. I don't expect it to be popular or even be printed at all but it is my personal favourite. Poetry, art and community health :-)

Click on the poster to enlarge.

Lousy T design idea

2008-07-10T00:11:00.005+05:30

Understanding Health For All

2008-07-05T16:23:00.005+05:30

There seems to be so much confusion regarding terminology within People's Health Movement. We hear talk of 'upper-case People's Health Movement' and 'lower-case people's health movement'. 'Health For All' seems to be the buzz word used by everybody today, from private insurance companies and corporate hospitals to Right to Health lobbyists and community health workers.

Here is Dr. Halfdan Mahler, the grand old man of the Health For All movement breaking it down in the simplest of terms. According to him the concept of Health For All is a value system/ spiritual belief. It requires a leap of faith. You have to believe that everyone is entitled to try and live in perfect health. You have to believe that any attempt to take away this freedom is wrong. Then you act.

Taking it from there, People's Health Movement is then the largest network of Health For All believers. It is the most visible face of such a belief. Using new technologies such as the internet and cheap air travel it unites individuals, organisations and networks to work towards Health For All at all levels. Its core manifesto is the People's Charter for Health, an action plan to achieve the world it believes in.

So People Health Movement is not a movement after all. It is the biggest network within the Health For All movement. If it was called the Network Of People Believing In Health For All And Then Deciding To Do Something About It then half the confusion would be cleared away. But there is no denying that PHM rolls of the tongue more easily than NOPBIHFAATDTOSAI.

If you dont believe that everybody, I mean everybody, has the right to try and live a life in perfect health then you cant use 'Health For All' in its profound, genuine sense. In the world we live in everyone suffers from some curtailment of this freedom. The poor, the sick suffer more. However such curtailment can never be morally right. While forcing people to live in unhealthy environments, preventing their access to the best possible medical care, allowing them to be subject to humiliation and hate may sometimes be temporarily unavoidable it can never be morally condoned.

An individual or institution who then uses the 'Health For All' term to promote itself but condones even the temporary infringement on people's Right to Health is then merely 'HFA washing' or 'hfasing'. Similar to pink washing, the phenomenon of corporate houses using breast cancer awareness and charity as an excuse to market their products. See Think Before You Pink for more.

To sum it up. The idealistic concept of Health For All finds practical expression in the lives of thousands of individuals and institutions who constitute the Health For All movement. The largest network of such believers is the People's Health Movement. However there seems to be others who use the 'Health For All' term carelessly and sometimes for selfish purposes.

Trust Me Ts design idea

2008-07-04T15:49:00.001+05:30

Click on the images to enlarge.

Varavara speaks my mind on reservations in medical colleges

2008-06-05T18:28:00.003+05:30

Merit Rule of Brahmin

a poem by Varavara Rao

Lucky
You are born rich
To say in your language
“Born with silver spoon in the mouth”

Your agitation sounds creative
Our agony looks violent

You are meritorious
You can break the glass of buses
In a shape

As symmetric as sun’s rays

You can deflate the tires
With artistic elan
While indulgent police look on
With their jaws rested on rifle butts

You can tie ‘Rakhis’
Even in
The dark chambers
Of a police station
You do not buy bus ticket
Not because
Your pocket is empty
That is practical protest

The beautiful roads
Are all yours
Whether you do a `Rasta Roko’
Or drive vehicles with `save merit’ stickers

We are bare-footed
Sweat-stinking road rollers
What if we built the roads?
The merit of plan is yours
The credit of contract is also yours

Those exhilarating sixty days, what fun!
When your cute little girls
And their daredevil mates
Were going on a delectable rampage,

Everybody was delighted
Parents, their parents
Brothers and sisters
Even the servants
And reporting Newspapers?
Oh, absolutely thrilled!

Boys and girls
Hand in hand
In protest
Of buried merit and dashed future
Going off to a picnic
O Yaar,
How heroic!

You are the marathoners
In merit competition
Poor tortoises
Can we run with you?

If
You serve “Chair” in Chikkadpalli
Sell “pallies” in cinema hall
Polish boots in Kothi Circle
Stop a Maruti or Priya on the Tankbund
To demand agitation fund

Well
Media persons are `merit’ creatures
Their camera hearts `click’
Their pens shriek,
“Youthful brilliance”!

We are drab faced duds
Sitting in the stink of dead animals
We make shoes
By applying color with our blood
And polishing them
With the sinking light of our eyes

However,
Isn’t the shine different
When polished
By someone in boots?

We clean up your filth
Carry the night soil on our heads
We wear out our bodies
Washing your rooms
To make them sparkle
Like your scented bodies

We sweep, we clean; our hands are brooms
Our sweat is water
Our blood is the phenyl
Our bones are washing powder
But all this
Is menial labor
What merit it has?
What skill?

Tucked-in shirts and miniskirts
Jeans and high heels
If you sweep
The cement road with a smile
It becomes an Akashvani scoop
And spellbinding Doordharshan spectacle

We are
Rickshaw pullers
Porters and cart wheelers
Petty shopkeepers
And low grade clerks

We are
Desolate mothers
Who can give no milk
To the child who bites with hunger

We stand in hospital queues
To sell blood to buy food

Except
For the smell of poverty and hunger
How can it acquire
The patriotic flavor
Of your blood donation?
Whatever you do
Sweep, polish
Carry luggage in railway station
Or in bus stand
Vend fruits on pushcart
Sell chai on footpath
Take out procession
With `Save merit’ placards
And convent pronunciations

We know
It is to show us that
Our labor of myriad professions
Is no match to your merit

White coats and black badges
Hanging over chiffon saris and Punjabi dresses
`Save merit’ stickers
On breasts carrying `steth’s (stethoscopes)
When you walk(ed) in front of daftar
Like a heaven in flutter
For EBCs among you
And those who crossed 12000 among us
The reservation G.O.
Is not only a dream shattered and heaven shaken
But also a rainbow broken

Yours
Is movement for justice
On the earthly heaven
That is why
`Devathas’ dared more for the amrit

The moment
You gave a call for `jail bharao’
In the press conference
We were shifted out
From barracks
To rotting dungeons
Great welcome was prepared
Red carpet was spread
(`Red’ only in idiom; the color scares even those who spread it.)

We waited with fond hope that
The pious dust of your feet
Would grace not only the country
But its jails, too

How foolish!
The meritorious cream
The future
Of country’s glorious dream
How can they come
To the hell of thieves,
Murderers and subversives?

We read and rejoice
That function halls
Where rich marriages are celebrated
Became your jails

Ours may be a lifelong struggle till death
But yours is a happy wedding party of the wealth
If you show displeasure
It is like a marriage tiff
If you burn furniture
It is pyrotechnical stuff
If you observe `bandh’
It is the landlord’s daughter’s marriage

Lucky
The corpse of your merit
Parades through the main streets
Has its funeral in `chourastas’
Amidst chanting of holy `mantras’

But Merit has no death
So
You creatively conduct symbolic procession
And enact the mourning `prahasan’
In us
To die or to be killed
There is no merit

We die
With hunger, or disease,
Doing hard labor, or committing crime,
In lock up or encounter
(Meritorious will not agree inequality is violence)

We will be thrown
By a roadside;
In a filthy pit;
On a dust heap;
In a dark forest

We will turn ash
Without a trace
We will `miss’
From a hill or a hole

Our births and deaths
Except for census statistics,
What use they have
For the national progress?

We take birth
And perish in death
In and due to
Miserable poverty
You assume the `Avatar’
When Dharma is in danger
And renounce the role
After completing the job
You are the `sutradhar’

You are lucky
You are meritorious.

Varavara Rao (b. 1940) is a member of Viplava Rachayitala Sangham (VIRASAM: Revolutionary Writers’ Association). He lives in Hyderabad.

Merton's violent activist

2008-05-04T14:20:00.000+05:30

“… there is a pervasive form of contemporary violence that the activist fighting for peace by non-violent means mostly succumbs, viz. activism and overwork. The rush and pressure of modern life are a form, perhaps the most common form of innate violence. To allow oneself to be carried away by the multiplicity of conflicting concerns, to surrender oneself to too many demands, to commit oneself to too many projects, to want to help everyone with everything, is to succumb to violence, more than that, it is cooperation in violence! The frenzy of the activist neutralises his work for peace, it destroys the fruitfulness of his own work because it kills the root of inner wisdom which alone makes work fruitful.”
– Thomas Merton

Teaching renal failure

2008-04-30T13:33:00.005+05:30

Teachers help students believe in patterns in the real world. In any discipline everything seems so chaotic and impossible to understand at first. The descriptions of patterns in our textbooks seem sterile and nothing like what we have seen in the real world. A desperate, breathless man with a wailing entourage looks nothing like what a textbook patient with end stage kidney failure is supposed to look like. My reading on poverty, class and caste conflicts wont let him breathe easy. Wont let me breathe easy. At Sittilingi I've had two patients like this already. One died holding my hand after twelve hours of struggling to breathe as fluid irreversibly poured into his lungs for the last time. One went home after being successfully pumped with diuretics. He will come another day to die.

Why do people die of kidney failure? Its a long complex story involving chronic NSAID abuse, undiagnosed hypertension, drugs prescribed by unqualified local 'doctors' and blinding ignorance of methods of prevention. Add to that poverty, exploitation and a historical tendency to screw over tribal communities.

What do the current pundits of community health have to say about managing people with kidney failure in the community. Precious little. There is a huge difference between those who do things and those who write about things. The doers are brilliantly innovative yet deathly silent. Amazingly innovative ways of managing such situations do not leave the local context where they are practiced. There exists no peer review journal, no website/blog, no conscious effort to put suchlike into current textbooks. On the other side we have the suave publishers. Toting degrees from posh institutions that inculcate snobbery they fly around collecting data and creating analysis that serves them well. However they act like they never met a poor, dying man ever. Never shared his pain.

I realize that my previous paragraph is harsh. I am in danger of putting myself on a pedestal. But I write because of frustration. Because I lack good teachers. Because my textbooks are nothing like the real world. The chapters on renal failure make no sense because they don't talk about patients. I know how to manage a rising blood urea level better than I know how to manage people dying. I cant prevent death because of the silence maintained on the people causing renal failure. By selling dangerous medicines and by their failure to create a working system people of my community cause people to die stupid deaths.

Its time we saw a chapter on renal failure that reflects reality.

Becoming an MFC writer

2008-04-30T13:22:00.004+05:30

My parents wrote in the MFC journal when they were little older than I am currently. Its managed to survive all those intervening years and the latest issue carries and article by me. Ruminating about what it meant to be a slightly lonely medical student. Check it out here (Its on the last page.)

Sometimes I cant really say whether I like the style it is written in or not. Why don't you tell me?

Dear Doctor

2007-12-27T01:49:00.000+05:30

We work shoulder to shoulder with quite a few informal medical practitioners in the Sittilingi valley. Most of them have learnt the trade by careful observation of other practitioners and supplement or substitute theory with a common folk understanding of the body. Occasionally they refer cases to us and then we get reference letters like the following.

To
The Medical Officer
Tripal Hospital
Chitling

Respected Madam & Sir
This certified that passant name Mr. M_________ dring the poisan so the recomtet the blood seckap to passant.

xxxx
MHMS, DY&N, RAMP, FRHS, MF(Homeo-Nigeria)

Carpenter fixed my leg

2007-11-26T23:11:00.000+05:30

A rural surgeon in Assam, an urologist by training has come up with an ingenious way of making up for his lack of expertise fixing complex fractures by internal fixation. He opens up the fracture site, then calls in the local carpenter whom he has taught the basics of surgical sepsis. The carpenter is quite adept at using standard orthopaedic drills, screws, metal plates, bolts and nuts to repair bones just as if they were delicate pieces of furniture. The urologist then repairs any vascular or nerve injuries and closes up. I guess the results would be comparable to that of the average Ortho registrar with only a few surgeries under his belt and in the absence of tertiary level orthopaedic care far better than leaving such cases untouched.

Public policy quacks

2007-11-21T18:02:00.002+05:30

Another interesting presentation at ARSICON 2007 was one by Dr. Meenakshi Gautham on her study on the treatment of reproductive tract infections by informal medical practioners in the Tehri Gharwal region. I won’t attempt to summarise her findings here. I will only concentrate on the finding that almost all the practioners had no concept of the infectious etiology of urethral and vaginal discharge yet almost all prescribed antibiotics for such symptoms. When the actual rate of infection was calculated among symptomatic patients who were prescribed antibiotics it was found to be quite low (3-5% if I remember right). Most patients who got antibiotics did not need them.

These practioners were using a different theoretical framework, a traditional humoral understanding of the body to explain their patient’s symptoms. However they then proceeded to use antibiotics which have been developed using a modern biomedical framework. Since a formal medical education was inaccessible to them due to reason of money and language they had no means understanding this biomedical framework and this in turn made their prescription practice excessive and dangerous. Although it was not brought out in the study, they were possibly also aware of the fact that prescribing more antibiotics meant more profits and more incentives from pharmaceutical reps.

The traditional humoral understanding of the body is common sense knowledge in the region where they lived and worked. Most informal medical practioners learn what drugs to prescribe by careful observation of other doctors and it is hence not unnatural that they attempt to fit such observations into the theoretical framework in which is most familiar to them. They invest antibiotics which properties of ‘heat’ and ‘cold’ just like traditional medicines.

What I found interesting was the parallels that can be drawn between such a scenario and that of doctors writing health policy at state and national level. A large number of doctors in government committees are super-specialist clinicians with years of experience operating within the modern biomedical framework. Modern medical education ensures that even those who have spent years seeing patients from poorer, rural communities have no theoretical basis for understanding the social, cultural, economic and political realities of their patients. Those with post graduate degrees in Community Medicine don’t fare much better. It is quite likely that the surgeon mentioned in my previous blog entry might sit on a committee looking into ‘Tribal Health in

India

’.

Most assumptions on which policy is then based stem from common sense and years of observation. We have already seen how this can be a dangerous practice, since a large number of observations do not automatically mean that one has even begun to understand even the basics of the underlying phenomena. Indeed the resultant policy prescriptions produce results that seem similar to those of informal practioners. A lot of money gets spent, a few people get better and a large majority remain as they are.

If we are to ensure that policy decisions are made on rational grounds then we need to ensure that those making such decisions have both a deep theoretical and practical understanding of the social and political reality they are attempting to affect. Given the choice we would not entrust our bodies to a surgeon if we realised that he either didn’t have the necessary theoretical understanding of the human body or the requisite amount of practical experience. Policy interventions which affect the lives of millions of people deserve no less.

Speaking of tribal communities

2007-11-21T18:00:00.000+05:30

I recently attended ARSICON 2007, the annual conference of a dedicated group of rural surgeons in India who form the Association of Rural Surgeons of India. The association is probably the only group of clinicians I have known who deeply and pragmatically care about the spiraling costs and increasing inaccessibility of basic surgical and medical care in

India

. For someone who spent five years as an undergraduate becoming increasing disillusioned with the rampant commercialisation at my Catholic institution their company was indeed uplifting.

Over three days I watched videos of extraordinary surgery aimed at minimalising costs for the patient, listened to a number of experienced speakers and generally became more absorbed in the art of surgery than at any given time during my years at medical college.

There was only one presentation that got a standing ovation and it is this presentation that disturbed me the most. A senior surgeon attempted to sum up ‘Tribal Health in India’ by presenting a few pictures of semi-clad forest dwellers, marsamic children and bloody bear attacks. All the pictures were 20 years old and in quite a few the person displaying tribal weapons was another rural surgeon, a fact that was not mentioned anywhere in the presentation. Tribals were portrayed as having ’No gods, no religion and only superstitious beliefs.’ No where was the actual name of the tribe portrayed mentioned. There were no statistics, no indication as to the reasons why tribal communities have been denied access to modern health care.. Scheduled Tribes constitute around 7% of the Indian population and actually are an extremely heterogeneous group. Such an incredibly simplistic representation did them an injustice to say the least.

What concerns me is that barring one or two surgeons, not a single person picked up the fact that the picture painted was crude and inaccurate. Here was a group of people who were not safely cocooned in an elite urban clinical practice yet after all their years in rural service they had no concept of what constituted a fair and representative description of tribal communities and what did not.

Like many other health systems, the Indian system is characterised by the fact that a majority of doctors come predominantly upper class, forward caste communities. A quick eyeballing of the ARSICON participant list will confirm this. If such doctors are truly desirous of understanding poorer, less privileged communities in order to help them then they need a basic theoretical framework in which to situate their understanding, This would be similar to the framework of anatomy, physiology, pathology and pharmacology which helps them understand surgical problems and techniques. Such a framework would include elements of basic sociology, anthropology, economics and political science and would help doctors navigate through the complex socio-political landscapes in which their patients are located.

Adding more theory to the MBBS course may seen to be an unfair demand at first. A quick review of the existing curriculum would reveal however that medical students are anyway burdened with a lot of complex biomedical theory which they have no use for. Why would anyone need to know the exact steps of the Kreb’s Cycle? Or the molecular structure of aminogylcosides? My suggestion is to replace this with basic social science theory instead.

Practicing here in Sittilingi it is ironical that when a young tribal woman is brought in after consuming poisonous plants containing cardiac glycosides I can elegantly describe the exact effect of the toxin on Na-K- ATPase cellular pumps but fumble when attempting to explain the social factors that caused her to attempt suicide in the first place. Neither can I fully explain the fact that pharmaceutical companies have decided that the specific antidote (digoxin Fab fragments) need not be marketed in India, a country where there is a large incidence of such poisonings. Such social and economic understanding would enable me to intervene much more effectively at both the individual and population level instead of merely being able to impotently explain the exact physiology behind her cardiac arrhythmias as she dies before my eyes.

Operating in Chinese

2007-11-18T17:56:00.000+05:30

In this era of globalisation in comes as no surprise to me that the artificial icepacks we occasionally use at our hospital have been manufactured in China. However I realise that a great many linguistic and cultural barriers have yet to be crossed when the instructions on the cover read as follows.

Operation Instructions

This element it is amazing not to have. “Store the cold foot” lowers the temperature fast to clear yp coldly and slowly.
Pack and open outside, the income -10◦C ice boxes or freezes are frozen hard and reservly soon.
It is insulate against heat protecting cold thing. In the case, according to protecting the cold demand, set up the quantity of good performance to pack into.
In the case the damage will not be polluted seriously protect the cold thing.

Dr. Claudio's One-Liners

2007-10-18T00:15:00.001+05:30

Dr.Claudio Schuftan, runs the PHA-Exchange, an international mailing list for those interested in the People's Health Movement and working towards ensuring health as a human right. Here is a sample post containing a collection of some of his one-liners.

1. Half truths are like half bricks: you can throw them further.

2. The rich countries perpetuate the myth that expertise is the prerogative of the few.

3. If we made poverty and malnutrition contagious across the globe, their elimination would be remarkably rapid.

4. The rich like to speak of one world, but actually they are worlds apart of the realities of poverty with its ongoing HR violations.

5. When poor people are suffering and oppressed, the last thing they need is a God of docile love and meekness.

6. In international affairs (including international HR law), countries of the South most often react, but just reacting limits their choices.

7. "If I am not for myself, then who is for me? And if I am not for others who am I? And if not now, when?".

8. Stop reinventing the wheel. Start putting wheels on the wagon.

9. The future has many names: for the powerful few it is status-quo, for the bold (among the not-yet-powerful-many) it is an opportunity for needed structural changes (that will tackle HR violations at their roots).

10. Struggle is a principle of development; to be is to do.

11. Faith in the power of doing is better than doing nothing at all.

12. Either we unite, organize and cooperate closely or many more will continue dying unnecessary deaths… United, we all have an opportunity to make a difference… Divided we beg, united we demand

13. Action unites more than words; the latter usually divide.

14. "Raise hopes, don't destroy illusions".

15. We are not to preach, but to organize mass actions.

16. The name of the game is: Focus on lasting/sustainable results, not on any dogma!

17. Because men and women experience poverty differently, we need to work harder on the rights of women (and those of minorities).

18. Perhaps it is unrealistic to expect poor women to overcome deeply ingrained socio-cultural barriers just because we empower them financially through micro-credit operations and/or we train them in leadership. For their rights to be ultimately respected, more than that will be needed…

19. An economic system that has little or no use for better than half of the world's population can and must be radically transformed.

20. The world economic order works for the advantage of 20% of its population.

21. Neoliberalism globalizes poverty, not development.

22. The debt of poor countries has already been paid by ever-falling-terms-of-trade. (That is why the HR-based framework calls for debt relief for the poorest countries).

23. Money equals force in the market; therefore, those with money dominate. So world trade is a means of domination of the rich countries.

24. The laws of supply and demand can fix the market price of bread, tortillas, cassava or rice, but they do nothing to alleviate hunger as a key HR violation.

25. The invisible hand of the market has no capacity to imagine or create a decent society for all.

26. Globalization does not have a human face; it has a cynical human mask.

27. In the era of globalization, progress means inequality and for its staunch promoters, reason means self-interest.

28. There is enough for everyone's need, but not for everyone's greed.

29. In the struggle for the alleviation of poverty, the check has come back from the 'Bank of Justice' marked "insufficient funds".

30. Income for the poor is perhaps the best guarantee of health and food security.

31. It took Britain the exploitation of half the globe to be what it is today; how many globes would India need?

32. As the threat from the many HR violations we see worldwide increases, so does the cost of inaction.

33. Social justice and the universal respect of HR will not succeed if it remains the sole concern of intellectuals.

34. Death is a social disease: How often do we overlook this axiom?

Getting my priorities right

2007-10-10T22:34:00.000+05:30

This month we are conducting an intensive campaign in the 21 villages of our health outreach programme to detect new cases of TB following a spurt in the incidence of the disease among newly returned migrant workers. This however sometimes adds a little surreality to my life.

Picture a bearded lab technician, a thin young doctor and an elderly Malavasi woman who is the local health auxiliary driving through the Avalur valley on a motorcycle. We stop at a house where the health auxiliary says she swears the man coughs a lot. He is not at home but has gone out with his goats. So the health auxiliary sets off down the road calling you his name while we sputter along behind her on the bike. Suddenly there is an answering call from up ahead. Soon an elderly man comes into view.

"Do you cough a lot, Aiya?", I ask as I dismount the bike. "Not really", he says, "But I occasionally have shooting pains down the side of my leg." "No cough? No fever? No weight loss?", I persist. "No, just leg pain", he replies. "He does cough", says the health auxiliary testily, possibly upset that her find is no longer allowing her prove that she has indeed surveyed the village for people with possible symptoms of TB. "Well, I occasionally cough at night", he finally admits. He soon finds himself sitting side-saddle on our motorcycle which is parked on the middle of the road while I auscultate his chest. The lab technician mutters darkly about the value of time. "Can you give us some sputum to test?", I ask. "I don't want a plastic cup", he says, viewing the proffered sputum cup suspiciously, "But if you have medicines for my leg pain I will surely take that."

Free Burma!

2007-10-04T23:39:00.000+05:30

Jesus has them too

2007-09-29T22:07:00.000+05:30

I guess that even evangelists occasionally manage to slip up. Especially when introducing a new convert to Christian culture and foreign sounding Christian names. So it happened that a few days ago a heavily pregnant Jesus walked into our labour ward providing me with ample opportunity to scream at the top of my voice "Push, Jesus, Push" and generally blaspheme in bad Tamil as she delivered a perfectly cute baby into my hands. Not many doctors from Catholic medical colleges get to say that two months after graduating they were already good enough to successfully deliver Jesus (smirk).

Mein Akela Nahin Hoon: The Story of Dr. Binayak Sen

2007-09-29T00:47:00.000+05:30

Return to Slow Medicine

2007-09-13T00:21:00.000+05:30

Today I walked in on a scene in our labour ward that would have been unusual in almost any other hospital I have known. We have two beds for women in the first stage of labour and Dr. R., the other junior doctor at Tribal Hospital was sprawled out on one of them, fast asleep. His hand however, reached out towards the other bed where it was grasped lightly in the hand of a sleeping woman exhausted by her prolonged labour. Both had been up for the last twelve hours, ever since the woman stepped into the ward. Dr. R., whose inclination for working with obstetric cases I must admit far surpasses mine, had spent a good bit of the preceding hours talking to the patient, massaging her back and generally coaxing her through a difficult, prolonged labour.

The idea of a doctor and patient falling asleep together while holding hands has the potential to cause a variety of responses amongst those in the medical field ranging from disapproval to alarm to dismissal as something that can occur only when a doctor has absolutely no other demands on her time. All these responses stem from the fact that as doctors we are trained to see patients as clinical cases first and as scared and suffering neighbours second. Right through my medical education at a big city hospital I had to imagine the situations and surroundings from which my patients came from and what it would like to be one of my patient's neighbours. None of my actual neighbours was ever seen by me since we were only allowed to practice our skill on the poorer patients in the general wards.

Working at Tribal Hospital in a re-education of sorts. There is no need to imagine my patients as neighbours. They are in fact my neighbours, working and living in the same environment as me. Almost all the staff except the doctors are women from the adjoining villages. Patients are no longer a row of bodies clothed in identical hospital garb. Instead most of them are personally known or related to the ward sisters. If you work here for a few months you would have visited a good number of the villages from most of our patients come from. I no longer send discharged patients to imaginary places but to streets I may have walked down myself.

The reason we spend time with our patients is simply because in such an environment ignoring someone who is sick or frightened is plain rude.

Can I still disagree?

2007-07-10T13:36:00.000+05:30

I wont discuss the intricacies of the arrest of Dr. Binayak Sen, a noted paediatrician and human rights activist in Chhattisgarh. Much has already been written about it. The SaveBinayak site is an excellent starting point. The internet activist can sign petitions here and here.

What is troubling for someone not involved in the local intrigues of the case is the strong statement that the Chhattisgarh State Government makes with such an action. By going after a man who strongly sided with non-violent, democratic means of countering State excesses and negligence the government is slamming shut the door to democratic activism and dissent. Taking up the line of George Bush, people can now choose to be either 'with us or against us'. The Chhattisgarh Special Public Securities Act, under which Dr. Sen is charged has sweeping powers and contains wording that can be interpreted in such a manner that a number of seemingly innocent acts can be construed as 'waging war against the State'. The Act seems to be targeted more towards so called 'Naxal sympathisers' than any armed revolutionary. Here is where the danger lies. Since the Naxal movement claims to represent and fight for the most oppressed sections of Indian society, the landless farmers and tribals, any person seen as sympathising with these people is now seen as a potential Naxal.

I grew up in the heart of the democratic movement that hoped to represent the poor and the oppressed in India. Never have I heard anyone openly admire Naxalite violence or any other sort of violence for that matter. People on the ground do sometimes however, acknowledge the frustration and hopelessness that occasionally drives people to take up arms. For the first time I am witness to a new fear within the community. People are now acutely aware of the value of political correctness in an atmosphere where a single careless sentence or act can be misconstrued as supporting violence aganist the state. Overnight the community has woken up to the fact that the political support from the middle class which viewed activists as people who have taken a much respected but less beaten path has evaporated. Any sort of activism is now seen as a bunch of idealists creating a nuisance at best and at worst activism is seen as terrorism. The line between democratic and non democratic dissent is fast eroding.

An environment in which you can get away with anything provided that you can create enough spin to make people believe that your enemies/victims are 'terrorists' is deeply disturbing. The vulnerableness of groups with no access to mass media and other channels where they can sufficiently and honestly portray there version of the truth is great. Skillful control of most Indian media by a nexus of businessmen, politicians and corporates contributes to this environment in which all protest has become theatre whether the script involves violence or not.

Any free and just society needs to provide space where citizens can confront the government and other powerful institutions. It is imperative for concerned people to fight to maintain and expand this space for democratic, constitutional ways of disagreeing with the Powers That Be. While there is still time and space.

Phoenix blog

2007-07-10T13:29:00.000+05:30

Its time to resurrect the blog. Again.

A quick update. My long drawn out medical studies are finally over and from August 2007 I will start work at the Tribal Health Initiative in Sittilingi, Tamil Nadu as a junior doctor. I hope this change in my setting will be reflected in a change in perspective and content of this blog. I hope to delve deeper into understanding the chaos which is the Indian health system and use this blog as a platform for opinion and discussion. As of now I am using this rare free month to travel as much as I can within North India.

Brecht sums up my reflections on the near completion of my degree

2007-03-08T10:40:00.000+05:30

To The Students Of The Workers’ And Peasants’ Faculty

1
So there you sit. And how much blood was shed
That you might sit there. Do such stories bore you?
Well, don’t forget that others sat before you
Who later sat on people. Keep your head!

2
Your science will be valueless, you’ll find
And learning will be sterile, if inviting
Unless you pledge your intellect to fighting
Against all enemies of all mankind.

3
Never forget that men like you got hurt
That you might sit here, not the other lot.
And now don’t shut your eyes, and don’t desert
But learn to learn, and try and learn for what.

A Worker’s Speech To A Doctor

We know what makes us ill.
When we are ill we are told
That it’s you who will heal us.

For ten years, we are told
You learned healing in fine schools
Built at the people’s expense
And to get your knowledge
Spent a fortune.
So you must be able to heal.

Are you able to heal?

When we come to you
Our rags are torn off us
And you listen all over our naked body.
As to the cause of our illness
One glance at our rags would
Tell you more. It is the same cause that wears out
Our bodies and our clothes.

The pain in our shoulder comes
You say, from the damp; and this is also the reason
For the stain on the wall of our flat.
So tell us:
Where does the damp come from?

Too much work and too little food
Makes us feeble and thin.
Your prescription says:
Put on more weight.
You might as well tell a bullrush
Not to get wet.

How much time can you give us?
We see: one carpet in your flat costs
The fees you earn from
Five thousand consultations.

You’ll no doubt say
You are innocent. The damp patch
On the wall of our flat
Tells the same story.

- Bertolt Brecht

Look at the Dalit basti!

2007-02-23T00:13:00.001+05:30

Look at the dalit basti
What plight of humans!
From the belly rises fire,
But the chulha can not be lit.
- Bahinabai Chaudhari (1888-1951)

I am not in chains, not in chains:
I a neither diseased nor I am a healer.
Am not a Moman nor a Khafir am I,
Neither a Mulla nor a Saiyed,
Why ask Bulle Shah his caste?
Neither I created caste, nor am I born in one.
- Bulleh Shah (1680-1748)

Brahmin, Vaishya, Shudra or Kshatriya,
Dom, Chandal or Mlechchha: All have the same soul.
They can all attain purity, singing hymns to God:
It will liberate both – self and generations.
- Ravi Das (1398-1448)

Sugar cane is rough; the juice in it is sweet,
The bow is not straight but the arrow is,
River zigzags, but not the water in it.
Chokha isn’t beautiful but the God in him is.
Why get misled by outward appearances?
- Chokha Mela (14th century)

Actions, says Dadu, rank higher that one’s caste,
Think not, therefore, of anything else;
Social ranking is tainted,
Illumined are only noble thoughts.
- Dadu Dayal (1544 – 1603)

Immortal is the land I come from;
There are no Brahmins, Kshatriyas, Shudras or Vaishyas
No Mughals or Pathans, nor Saiyeds or Shaikhs;
The message humble Kabir brings, in essence, is:
Let’s go to that land.
- Kabir (1398-1518)

This set of poems is from a calender designed by Loknaad.

The Aphorisms of Rudolf Virchow

2007-02-03T03:07:00.000+05:30

Rudolf Ludwig Karl Virchow (1821 – 1902) was a German doctor, anthropologist, public health activist, pathologist, prehistorian, biologist and politician. His famous report titled Report on the Typhus Epidemic in Upper Silesia is an absolute classic and established him as one of the founding fathers of social medicine. Among his many talents Virchow was adept at coming up with catchy aphorisms. These are some of my favourites:

“Medicine is a social science, and politics is nothing but medicine on a large scale.”

“It is the curse of humanity that it learns to tolerate even the most horrible situations by habituation.”

“Medical education does not exist to provide students with a way of making a living, but to ensure the health of the community.”

“The physicians are the natural attorneys of the poor, and the social problems should largely be solved by them.”

“My politics were those of prophylaxis, my opponents preferred those of palliation.”

“Virchow had a comprehensive vision. Pathology, social medicine, politics, anthropology. My model.” – Paul Farmer. Mine too :-)

A community health oriented Indian Christian

2007-01-28T15:10:00.000+05:30

‘The Jews expected a messiah, and perhaps they had hopes of Jesus. But they were soon disappointed. Jesus talked a strange language of revolt against existing conditions and the social order. In particular he was against the rich and the hypocrites who made religion a matter of certain observances and ceremonial. Instead of promising wealth and glory, he asked people to give up even what they had for a vague and mythical Kingdom of Heaven. He talked in stories and parables, but it is clear that he was a born rebel who could not tolerate existing conditions and was out to change them. This was not what the Jews wanted, and so most of them turned against him and handed him over to the Roman authorities.”

- Jawaharlal Nehru (1949, 85)

“Christ took pity on people and came to their aid, whether they were spiritually ill as a result of sin or physically sick. His attention was given to the sick person with whom he frequently talked, showing his preference for the poor but without excluding anyone in need who appealed to him.

Jesus considered suffering and sickness as forming part of the ‘less human’ situation and we are asked to endeavour to make these ‘more human’.”

“Since Christians are the leaven, we must reach out towards the masses by providing simple, accessible and promotional health care according to our own possibilities, modest as they are, or in conjunction with the public services, where this is allowed.”

- cf populorum progression, 20

“And because the life of Jesus has the significance and transcendence to which I have alluded, I believe that He belongs not solely to Christianity, but to the entire world; to all races and people, it matters little under what flag, name or doctrine they may work, profess a faith, or worship a God inherited from their ancestors.”

- Mahatma Gandhi

Action Heroes Wanted

2007-01-24T12:33:00.000+05:30

Blank Noise is a public and participatory art project working both online and on the streets of Bangalore, Mumbai , Delhi, Chennai and Hyderabad. Blank Noise seeks to recognize eve teasing as street sexual harassment and establish it as an issue.

Blank Noise project Bangalore calls for women/ girls/ ladies/ of all ages, languages, colour, and shape to be participate in a street intervention on Sunday January 28th. By participating you will be celebrated as a BNP Action Hero. Confirm /ask questions at 98868 40612. This street intervention will be approximately 1.5 hours ( 5 - 6 30 pm).

Find out more at the Blank Noise Project Blog

Communicable disease among rabbits

2007-01-21T12:21:00.000+05:30

Untitled

Rabbits they say
Are very scarce to-day
My diagnosis?
Myxamatowsis.

- Spike Milligan
-------------------------------

Myxomatosis

Caught in the center of a soundless field
While hot inexplicable hours go by
What trap is this? Where were its teeth concealed?
You seem to ask.
I make a sharp reply,
then clean my stick. I'm glad I can't explain
Just in what jaws you were to supporate:
You may have thought things would come right again
If you could only keep quite still and wait.

- Philip Larkin (1955)
-------------------------------

Myxomatosis

The mongrel cat came home

Holding half a head

Proceeded to show it off

To all his new-found friends

He said, "I've been to where I like.

"I've slept with who I like.

"She ate me up for breakfast.

"She screwed me in a vice.

"But now,I don't know why I feel so tongue tied."

I sat in the cupboard

And wrote it down in neat

They were cheering and waving

cheering and waving

twitching and salivating

like with myxomatosis.

But it got edited fucked up

Strangled beaten up

Used as a photo in Time magazine

Buried in a burning black hole in Devon

And now, I don't know why I feel so tongue tied.

Don't know why I feel so skinned a- live.

My thoughts are misguided and a little naïve

I twitch and I salivate

like with myxomatosis.

You should put me in a home or you should

Put me down

I got myxomatosis.

Yeah and no one likes a smart arse

But we all like stars(Oh please)

That wasn't my intention(blah blah)

I did it for a reason (reason)

It must've got mixed up

Strangled

Beaten up

I got myxomatosis.

And now, I don't know why I feel so tongue tied.

- Radiohead. Hail the Thief (2003)

-------------------------------

Myxomatosis

A baby rabbit
With eyes full of pus
This is the work
Of scientific us

- Spike Milligan

-------------------------------

Myxomatosis (from the Greek μύξα (mucus), and ματώνω (to bleed)) is a disease which infects rabbits. It is caused by the myxoma virus. First observed in Uruguay in the early 1900s, it was deliberately introduced into Australia in an attempt to control rabbit infestation there.

Novartis, drop that case!

2007-01-17T18:12:00.001+05:30

In August 2005 I had written two articles on this blog on the rewriting of the Indian patent laws using the controversy surrounding Gleevec, an anti-cancer drug by Novartis to illustrate the issue. Under the new patent regime, large pharmaceutical companies could take out product patents which would allow them to monopolise production of new drugs and increase prices.

In January 2006, Novartis' patent application for Gleevec was rejected on the grounds that the drug was a new form of an old drug and therefore was not patentable under Indian law. This enabled patients with certain cancers to access the drug at a price of around Rs. 9000 ($200) a month as opposed to a price of 1,15,000 ($2600) which was the price of the drug elsewhere.

Currently Novartis is suing the Indian Government in order to have the patent decision overturned so that it can sell Gleevec at the same price in India as in other countries. If Novartis wins the case and succeeds in getting the provision of Indian law changed to resemble patent laws in wealthy countries, it could mean that fewer and possibly no generic versions of newer drugs will be able to be produced by Indian manufacturers during the first 20 years after discovery of a drug and India will no longer be able to supply much of the developing world with cheap essential medicines.

Sign a petion to demand that Novartis drop its case against the Indian Government.

Read more about the issue at the Medecins Sans Frontieres site.

Another acorn!

2007-01-17T03:29:00.000+05:30

How can you resist a blog subtitled "Epidemiology, truth and counter cultures" ? Rakhal has been a great friend, philosopher, guide and cousin over the years but seems to have kept his blog in the closet. Until now.

The oak tree out of which the acorn fell

2007-01-02T00:24:00.000+05:30

After a large amount of persuasion and calming of apprehensions the NarayanBlog is up and running! Read and leave sweet encouraging comments here.

Must Reads: Medical Nemesis

2006-12-31T01:31:00.000+05:30

I've been reflecting recently on some of the books I've read as a medical student apart from our volumnious textbooks and I think it would be interesting to start a series on this blog about essential additional reading for any medical student particularly in the Indian context.

I think the hands down winner for Most Influencial Book is Medical Nemesis: The Expropriation of Health by Ivan Illich simply because it humbles you. In an atmosphere where doctors are becoming sickening self-congragulatory about the increasing use of technology in medicine which enables us to intervene and control bodily phenomena like never before, Illich reminds us that medicine, just like everything else has is limits beyond which is cannot hope to do good. Here is a sample.

Increasing and irreparable damage accompanies present industrial expansion in all sectors. In medicine the damage appears as iatrogenesis. Iatrogenesis is clinical when sickness and death result from medical care; it is social when health policies reinforce an industrial organisation which generates ill health; it is structural when medically sponsored behaviour and delusions restrict the vital autonomy of people by undermining their competence in growing up, caring for each other and aging or when medical intervention disables personal responses to pain, disability, impairment, anguish and death.

The book was first published in the 1970's and is sadly almost unknown among medical circles today. I have still not found a bookshop in India that stocks it though it is available on amazon.com. I myself had to fall back on the time honoured technique of photocopying the only remaining library copy. Read it.

The social context of Indian medicine

2006-11-18T15:18:00.000+05:30

I'm currently posted in Chamrajnagar, a rural district in South Karnataka and am practising in a social setting that gives me a lot of food for thought ..

Indian medical practice is largely based on clinical research conducted in the West. Most of the internationally recognised standard texts are by North American or European authors. The teaching methodology used here is largely an outdated, didactical approach which was imported here in the 50’s and 60’s when a large number of medical colleges were set up post independence.

However the social context in which our system is embedded is radically different from the one on which our system is based. While the Westernised elite are more likely to demand and have access to health care it is the poor, who are in an overwhelming majority who really require good, relevant health care. This is because poverty is intrinsically linked to sickness, a large component of which is preventable or easily curable.

It is quite evident that a majority of doctors respond to this difference between theory and reality with a range of practical modifications which range from the simple and obvious to the highly sophisticated. However they still exist only at the level of individual endeavors and as yet there is no large systemic acceptance and addressal of our unique reality.

Doctors in India are also handicapped in their understanding of the social context in which they practice for two reasons: One is that since entrance to medical colleges is highly competetive and students from private schools have an enormous advantage during entrance exams, doctors as a group come predominantly from upper class, upper caste backgrounds whereas a majority of people in real need of health care come from lower class, lower caste backgrounds. The second reason is that since admission to medical college is open to students only from science streams in India, doctors complete their education with only a miniscule component in social sciences as part of their Preventive and Social Medicine syllabus which exists more for namesake than anything else. Hence they are ill equipped to analyse, research and act upon any problem that is not quantitative and out of the realm of pure science.

It is this lack of understanding of social context that has prevented modern Indian medicine from being truly relevant in rural India, where the medical need is immensely greater than in urban areas. The crying need of the day is for Indian doctors to move out of the biomedical paradigm and become anthropologists, communicators and true practioners of revelant social medicine.

Pixels

2006-08-17T00:02:00.000+05:30

Thanks to Snake Anthony I have finally managed to put a whole lot of my pictures online on Flickr. Check them out here.

A mere two Israeli generations ago

2006-08-14T20:26:00.000+05:30

"In Germany first they came for the communists
and I did not speak out-
because I was not a communist.

Then they came for the Jews
and I did not speak out-
because I was not a Jew.

Then they came for the trade unionists
and I did not speak out-
because I was a Protestant.

Then they came for me-
and there was no one left
to speak out for me."

-Pastor Martin Niemoller (1892-1984)
A leader of the church's oposition to Hitler.

Travelling in the Narmada Valley ..

2006-05-31T18:49:00.000+05:30

What did you do when the poor
suffered, when tenderness and life
were dangerously burning out in them?

Apolitical intellectuals
of my sweet country,
you will have nothing to say.

A vulture of silence
will eat your guts.
Your own misery
will gnaw at your souls.
And you will be mute
in your shame.

-Otto Rene Castello.
Guatemalan poet who was killed by the Guatemalan army on March 19, 1967.

Explaining Why Not

2005-11-16T20:12:00.000+05:30

The Master was known to side with the revolutionaries even at the risk of incurring the displeasure of the government.

When someone asked him why he himself did not actively plunge into social revolution, he replied with this enigmatic proverb:

“Sitting quietly doing nothing.Spring comes and the grass grows."

Quoting Paul Farmer

2005-11-15T20:00:00.000+05:30

This man has the most fascinating collection of quotes. These are my favourites.

“I will define what I conceive medicine to be. In general terms, it is to do away with the suffering of the sick, to lessen the violence of their diseases, and to refuse to treat those who are over-ministered by their diseases, realising that in such cases medicine is powerless."
- Hippocrates
“The Art”

“For if medicine is really to accomplish its great task it must intervene in political and social life. It must point out the hindrances that impede the normal social functioning of vital processes and effect their removal.”
-Rudolf Virchow

“Our system is one of detachment: to keep silenced people from asking questions, to keep the judged from judging, to keep solitary people from joining together and the soul from putting together its pieces.”
-Eduardo Galeno
“Divorces”

A Worker's Speech to a Doctor

2005-11-14T19:33:00.000+05:30

When we come to you
Our rags are torn off us
And you listen all over our naked body.
As to the cause of our illness
One glance at our rags would
Tell you more. It is the same cause that wears out
Our bodies and our clothes.

The pain in our shoulder comes
You say from the damp: and this is also the reason
For the stain on the wall of our flat.
So tell us:
Where does the damp come from?

-Bertolt Brecht

The Gleevec Story: Part 2

2005-08-13T19:21:00.001+05:30

This is the second part of the article. See below for Part 1.

The pharmaceutical industry and other ancillary industries which depend on modern allopathic medicine make only a weak pretense at being anything but profit making entities. This is fine as long as the physician acts as the intermediary between them and the patient, determining objectively when a patient really needs a particular pharmaceutical product.

However what has dramatically changed over the last two decades or so is that with the advent of globalisation and the birth of the multinational corporation, pharmaceutical companies find that in addition to stupendous profits, globalised trade also allows them to wield enormous amounts of power to influence international and local trade policy as well as the decision making capabilities of healthcare institutions and individual doctors. Time and again they have used this power to further their interests even when their decisions have adversely affected people’s access to essential medicines.

The only effective tool to influence a profit driven corporation is one that reduces profit. The need of the hour is to build a strong consumer movement which can protect itself through effective mechanisms that put pressure on big pharmaceutical corporations. World over it has been shown that when confronted with resolute consumers determined to ensure fair marketing practices, corporations have rarely risked profit endangering bad publicity and in many cases have backed down.

Doctors everywhere have a clear choice ahead of them. Whether to side with corporate bodies and become in effect corporate doctors with six figure salaries and a full range of pharmaceutical sops but no power to stand up against a corporate decision or whether to side with their patients and demand that people’s needs are put before profits, a position which guarantees a lower pay scale, more work, greater freedom and a fuller sense of job satisfaction.

This is a choice that our current system of medical education which is conspicuous in its silence about ethical issues and a strong economic and political understanding of the pharmaceutical industry leaves us ill-equipped to make.

The Gleevec Story: Part 1

2005-08-11T19:26:00.001+05:30

This is the first part of an article which I wrote for Raw Nerves, our nascent college newsletter. The second part is soon to follow.

On April 17, 2001 a new drug called Gleevec was officially announced by Novartis, the second largest drug company in the world. Gleevec or imatinib which is its pharmaceutical name works by interfering with the pathways that signal the growth of tumour cells. Overnight the drug revolutionised the treatment of CML (chronic myeloid leukemia) as well as GIST (gastro intestinal stromal tumours). The scientific community was greatly excited by the development of such signal transduction inhibitors and there was hope that soon similar drugs could be used to treat various other types of cancer.

Imatinib turned out to be extremely good news for the 24000 patients who are diagnosed with CML every year in India. As per existing patent laws in India, which allowed patenting of the manufacturing process but not the final product, imatinib was soon produced by nine different generic manufactures and was made available to patients at Rs. 9000-12000 per month. This was in glaring contrast to the Rs. 1,20,000 per month which was the cost of the branded Gleevec sold by Novartis.

In 2004 things took an ugly turn when Novartis managed to secure from the Patent Controller an EMR (Exclusive Marketing Right) for Gleevec. Almost immediately the Madras High Court was forced to order six of the generic manufactures of imatinib to stop production based on a case filed by Novartis. The decision spelled death for a majority of CML patients who could not afford the Rs 1,20,000 for the branded Gleevec.

To make matters worse in December 2004 the Central Government tried to push through a piece of legislation known as the 3rd Patent Amendment Bill in order to meet India’s commitment to the World Trade Organisation’s TRIPS Agreement which required that we amend our patent laws to allow for product patenting. Such a law would make EMRs like the one granted to Novartis standard practice for any new drug and would prevent people from accessing cheaper generic versions.

Health activists around the world were quick to recognise the potentially disastrous implications of the amendment and organised themselves under the banner of the Global Campaign against the Indian Patent Amendment. Protests were organised in Europe and North America as well as throughout India.

After many modifications the final version of the Bill was finally accepted by the President on 7 April 2005. The Bill ushered in a product patent regime in India but allowed generic manufacturers like those of imantinib who had made “significant” investment to continue production after a “reasonable” royalty has been paid to the patent holder such as Novartis. Such vagueness of the terminology can be easily exploited in favour of the patent holders. In many cases generic manufacturers were reluctant to restart production fearing lawsuits from the patent holders or unreasonably high royalties.

Under the new law, if the next signal transduction inhibitor drug which works against another form of cancer was discovered, then the patent holder, in most cases a large pharmaceutical corporation will have the exclusive right to market it for the next 20 years. In the presence of such a monopoly they will be able to get away with exorbitant prices.

The story of Gleevec highlights a growing phenomenon in modern day medical practice. That the health of our patients can be adversely affected by trends in globalised trade and that in order to safeguard our patient’s health doctors will have to understand and be active participants in a worldwide movement to counter the ill effects of globalisation.

Neevu Engleesh Daktara?

2005-03-12T19:23:00.000+05:30

Language in Medicine

One wonders why the study of language is not a more integral part of the study of medicine. Especially here in South India where it is not uncommon to encounter over six to seven languages in a single morning at the OPD.

The presumption is that all Indian doctors are natural born linguists. This is true to a certain extent with most of the senior doctors who seem to be able to take a basic history in a fair number of languages. Often however the interaction merely consists of a few basic questions and recycled advice. Real conservation in which the doctor can relate to the patients is difficult and requires a fair amount of experience and skill.

The people who feel the language barrier the most are the medical students and junior doctors who suddenly find themselves in possession of a fair amount of medical knowledge and absolutely no way of adequately communicating this to the people to whom it matters the most, the patients.

In this era of globalisation the issue of language and communication is all the more relevant. Large scale migration, especially to the cities ensures that at least in the urban setting doctors will always have to deal with patients from a multitude of linguistic and cultural backgrounds.

Miscommunication is at the heart of the recent rise in the number cases of litigation against doctors by irate patients and carers who feel that there expectations and rights have been betrayed. Obviously the most glaring forms of miscommunication occurs when the doctor and patient do not share a common language and have no means of overcoming this barrier.

In this context a more organised approach to the challenge of producing multilingual doctors is the need of the hour. The assumption that doctors will pick up language 'on the job' needs to be reevaluated and alternate approaches need to be looked at.

The teaching of languages has undergone a radical transformation over the last fifty years. Most Western universities have language laboratories where new and innovative methods of acquiring language ability are being explored. The challenge is for the medical profession to incorporate these advances in its effort to provide better and more effective care.

Celluloid Medicine

2005-02-25T19:18:00.000+05:30

The other day I was browsing through old issues of the BMJ at the British Council Library when I came across a study on whether screening films that portrayed doctors realistically helped medical students develop emphathy. The article contained the following lists.

Most useful films for medical education

1. The Doctor (1991)
2. Arrowsmith (1932)
3. The Citadel (1938)
4. Not As A Stranger (1955)
5. Pressure Point (1962)
6. Whose Life is It Anyway (1981)
7. Miss Evers Boys (1997)
6. The Interns (1962)
9. Critical Care (1997)
10. And the Band Played On (1993)

Best portrayal of doctors in films

1. Red Beard (1965)
2. The Hospital (1971)
3. Article 99 (1991)
4. State of Emergency (1993)
5. Miss Evers Boys (1997)
6. The Elephant Man (1980)
7. Panic In The Streets (1950)
8. Spellbound (1945)
9. Death And The Maiden (1994)
10. Guess Who's Coming To Dinner (1967)

The Characteristics of a Physician

2005-02-23T19:12:00.000+05:30

The introduction to Harrison's Principles of Internal Medicine has this beautiful excerpt from he first edition of the book in which the original authors aim to sum up the essential physician. The current edition apologises about the seeming chauvinism of the original text and reminds us that women physicians were still an oddity back then. I thought a little affirmative action was indicated so here's a re-edited yet continuingly gender biased version of the same.

The Characteristics of a Physician

No greater opportunity, responsibility or obligation can fall to the lot of a human being than to become a physician. In the care of suffering she needs technical skill, scientific knowledge and human understanding. She who uses these with courage, with humility and with wisdom will provide a unique service for her fellow human and will build an enduring edifice of character within herself. The physician should ask of her destiny no more than this, she should be content with no less.
Tact, sympathy and understanding are expected of the physician, for the patient is no mere collection of symptoms, signs, disordered functions, damaged organs and disturbed emotions. She is human, fearful and hopeful, seeking relief, help and reassurance. To the physician as to the anthropologist, nothing human is strange or repulsive. The misanthropic may be a smart diagnostician of organic disease, but she can scarcely hope to succeed as a physician. The true physician has a Shakespearean breadth of interest in the wise and the foolish, the proud and the humble, the stoic hero and the whining rogue. She cares for people.