Safe cab rides do not have to be a pipe dream

In the wake of the horrific news from Delhi of yet another rape – this time in an Uber cab – and with the terrifying knowledge that it could just as easily have been any one of us, I have compiled the following as minimum measures that are required of taxi companies to assure us of the safety of their services. Much in the list is standard practice in other countries. All we need to do is simply replicate. Please send in any further ideas or suggestions. If we can get the government to mandate these simple measures and ensure that their adoption, by the cab companies, is time bound and strictly regulated, we would have journeyed a long way to make road travel a safer experience for all.  Thank you for reading.

FOR TAXI COMPANY

 

FOR PASSENGER

1.      Transparent plastic secure barricade between the front of the car and the passenger section

 

 

2.      Meter to be installed in both driver and passenger sections

 

 

3.      Payment facility in the passenger section. Credit card machine and connecting slot for cash payments

 

 

4.      Driver’s Name. License, Phone Number, Address and Police Verification tag displayed in large notice stuck to the back of the front seat

 

Take a picture of this detail and send it (text/email) to family or friend

 

5.      Active and switched on in-camera surveillance

 

 

6.      Active and switched on GPS monitoring

 

 

7.      Once passenger is in the car, send text message to BOTH passenger and driver that the camera and GPS is now active and being monitored

Ensure the receipt of the text message from the taxi company confirming active surveillance and ONLY THEN allow the journey to commence

Forward this text to family or friend

 

8.       

Be aware of your surroundings at all times and preferably in constant phone communication with family or friend

 

9.       

Keep payment readily available at hand before destination

 

Mirages

This light, in this one place, drapes old years with new glow

Gathers together flaccid flesh, to cast in tight shadow

In it you will recognize my own youth

In a shape that left behind no remembrance.

Here, in this angle, in this light drape; it is yesterday again.

I must be still. This shade must grow root and ground

This stem like waist, the hair flip, the sinuous lines of my legs –

Until marginal etchings sweep smooth over pleated skin –

And memory’s motes melt in Erebus’s arms.

There held tight, all together, in entombed communion.

It stills. It waits. For you to take notice.

I tire and unconscious shift into the familiar hideous

The edifice splinters and detritus spills over

Floating back to sight; now as speckled incandescence

You don’t notice that either.

You are preoccupied with the other in the mirror

Oblivious to all that just passed by.

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Art Credit: Interior, Strandgade 30’ and ‘Encore et Toujours; Vilhelm Hammershoi

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The Intellectual. Definitions and discontents

And so, it seems, the FP list of thinkers for 2014 is also now released. In a new format that FP has tried for a couple of years, the list is not more than an insipid chronicle of achievers in categories – not quite the sort of list that could spur argument or discontent. In that regard, Prospect’s list was far more satisfying. This was written when Prospect released its list a little while back but, it was left to languish in an ever growing pile of drafts. Now is as good a time as any to post.

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The Prospect list of world thinkers for 2014 was released a few months back but, unlike other years, it turned into a damp squib despite the presence of four Indians in the top six. Perhaps it was ennui with predictable names claiming their spots every year or perhaps, interest around the subject is waning. Regardless, lists grab our fancy due that they guarantee a fight and on that score at least this one satisfied. Expectedly too, tempers frayed on the negligent exclusion of names considered more deserving. In India, as elsewhere, some of these names provoke strong opinion and, in a heated election year, has brought to fore again the subject of intellectuals and their role in society.

The discussion over who is an intellectual, even if hackneyed, is never boring. Common public perception of the class is as, ivory towered pulpit popes out of touch with ordinary realities. It is a reasonable contention that some of the isolation comes with the territory. But, it would be disingenuous to insist that this is often not aided by effort especially when one is actively setting out to be an intellectual. The argument is deeper than disconnected exclusion. It spans troubles that trail from definitions, through ideological recalcitrance, and beyond.

With the democratization of knowledge and information, intellectuals are now being subject to a new kind of scrutiny markedly different from that of the familiar peerage – that of an increasingly curious, questioning and generally lay public. In response, most have treated the shift with haughty disdain but, a few have welcomed opportunity in mass engagement ushering in the entry of a new and more commodious species – the public intellectual.

Much has been written about intellectuals, their characteristics and roles. Even if, across the board, scholarship and representativeness have come to be universally recognized as necessary features, opinion differs on critical specifics.  Thought on the subject has evolved from Emerson – who believed that each individual should aspire to be one by learning from nature, history and the experience of action; through Gramsci – for whom the intellectual was a representative working class man with motivated interests; to Benda and Foucault – who emphasised the role of domain experts rising above professional shackles to truth; to Bauman – who saw the intellectual as interpreter and to Edward Said – who advocated a conscientious dissenting role.

Colloquially, the word ‘intellectual’ is used interchangeably with ‘scholar’. This is a loose interpretation but one that has some basis. It is true that an intellectual has scholarly inclinations; the converse, however, cannot be automatically assumed. Despite this obvious understanding; the conflation happens often enough with consequences that follow an observable pattern that goes something like this: The scholar with the aid of the media stakes a proud (if wanton) claim to the ‘intellectual’ tag. The scrutiny that follows predictably crashes the hype and with the expected denouement of the reactionary take-down.

More appropriately, an intellectual is closer allied with a thinker than with a scholar. He/she not only has learning at command; but is also able to transcend the limits of scholarly prescription and detail the wide-angle view. Scholarship alone will not do. Neither will lofty intent that is not backed by the legitimate argument of penmanship. The seed of intellectualism is sown in the marriage of the two.

Unfortunately, the proliferation of mass media has eroded the legitimacy requirement and allowed talking heads to usurp a critical space. There are ways in which a scholar is recognizable as a thinker: 1. Thought and its analysis stem from reason not from biased preference, 2. There’s a discernible demonstration of interest in understanding and analysing an opposing point of view and, 3. Opinion is offered with humility and without condescension. A thinker’s analysis is informed by the philosophical approach. His opinion exhorts the mean to a greater bar. Ethics and integrity are the cornerstones of conduct and these choate qualities are capped with the courage to speak truth to power. As the voice that holds power accountable, intellectuals need necessarily to be invested with intractable moral authority. This anti-establishment requirement renders them as both, outliers and outsiders.

If this seems like a high bar to define an intellectual; it is. It is also the reason why their place is most haloed in society. Such positions can neither be devalued nor can the criteria for admission to their ranks be diluted. And so, while the democratization of the intellect  is an excellent development for society; it is important that the terms of definition are not confused and that the distinctions between an academic scholar and a public intellectual are clearly drawn.

Akin to the exceptionalism mentality in the US; the prevailing socialist and selective secularist mentality in India has, for a long while, been the pivot around which institutions, interests and intellectuals have swirled, brooking no challenge from alternate points of view. From the perspective of the intellectual, existing institutional and think-tank cultures reduce them to agents of ideology with few avenues of independent expression.

But, the view from the other bank, where opinion flies fast and furious, is one of discontent targeted most at the breed aptly named by Milosz as, the ‘servile intellectual’. Happily, this disaffection has found an outlet – it is now channelled through new voices from the liberating platform of the internet. In a curiously concentric movement, a form of Gramscian intellectualism has taken root. Educated youth from the working classes through internet platforms, blogs and social media are challenging the hegemony of power of both the mass media and the ruling cognoscenti. Even if the nature of this new medium tilts toward a truth shorn of nuance, it is increasingly recognized as a necessary and dynamic development.

It is at this juncture, that we, the enlightened public, must pay heed to our own abilities to be both the mirror and the voice. The process of honing an intellectual depends as much on the audience as it does on his or her own proficiencies. It is a good intersection that we find ourselves in. One wherein the interactions of organic lay intellectuals with public professional intellectuals, shape and mould each other and society.

And so, if I was to make a list of public intellectuals, inspiring representatives of the enumerated ideals, that list would include:

Every poet-philosopher (Shakespeare leads the group by some miles), the Tamil poet-activist Subramania Bharati, Edward Said, the saint-philosopher Shri Chandrashekara Saraswathi of Kanchi, Mahatma Gandhi, Jean Paul Sartre, Rabindranath Tagore, Naguib Mahfouz, Alexander Pope, WEB Du Bois and countless more.

From our times, Arun Shourie, Peter Singer, Roger Scruton, Thomas Nagel and EO Wilson would make my list.

Who would find place on yours?

Bins Before Brooms, Mr. Prime Minister!

A month back, the Prime Minister launched the Swachh Bharat Mission (SBM) with a personal touch amidst much public fanfare. It is not a common sight to see a Head of State sweeping a public street with a broom. Even less common is it to see one such picking up and disposing the swept litter! Cynics will surely say tokenism but, against the background of his relentless exhortations to sanitation, that remains, for now, a shaky charge.

SBM differs from its earlier avatar NBA (Nirmal Bharat Abhyan) by having segregated divisions for Rural (Gramin) and Urban sanitation. The former falls under the Ministry of Drinking Water and Sanitation and the latter under the Urban Development Ministry. The emphasis in both arms is on the building of toilets.

The new scheme has auspicious portents. The realization that community participation and outreach is critical to the success of  policy roll-out is one such. Both social media and the gov.in website (a platform for public participation in governance) record an uptick in community involvement. Indian television is carpet-bombed with informative and actionable ads slickly produced and fun to watch. One even calls for public shaming! Corporate India too is in on the action. Companies like TCS, Vedanta, Reckitt Benckiser and L&T have pledged upward of 100 crores each as CSR investment in rural and school sanitation and, industry body CII will now spearhead the construction of 10,000 toilets annually.

Urban sanitation has a Central allocation of 15,000 Crores to be disbursed over five years against an expected total cost of 62,000 Crores. The Centre also plans to utilize 7000 Crores (50%) to Solid Waste Management. For urban dwellers the attention to waste management is heartening but details are few on how the money will be spent or, on the accountability of the States who have the lion’s share of the responsibility.

Meanwhile, SBM was launched in the heart of the Capital with much exhortation of the public to participate in a cleaning drive. While so doing, we were asked to nominate tag teams (a la the Ice Bucket challenge) to keep the task of cleaning public spaces in continuous motion.

The bizarre took a turn for the worse when a dubious set of ‘celebrities’ – a group who, most likely, have never wielded a broom in their lives – were announced as the prime tag team, tagged by the Prime Minster himself. The announcement of this tag-game and its pretty players was an unnecessary and frivolous touch that instantly diminished the gravitas of the exercise. Imagine instead the impact of a team of Paurakarmikas (sanitation workers), on the stage with the PM, as recipients of a nationally televised commendation by him for their work. It is these people who are at the front lines of sanitation, who know the rigors of the exercise and, who will get the job done. Shining the spotlight on their work would have directed attention to sustainable outcomes. Instead, they watched from the side-lines as ‘celebrities’ basked in the counterfeited shine of welfare starlight.

Community participation however essential, is only a small step on the road to sanitation. More critically, community involvement has to be positioned closer to the last mile for interest to be sustained. The road to the last mile will have to be a lonely one that government travels. It is for government to invest heavily in the necessary infrastructure, in the gear for sanitation, before exhorting the public to cooperate. This seeming shift of focus is where SBM disappoints.

Let me illustrate the importance of gear with a personal story about urban sanitation. I was recently back home in Bangalore. Home there is in a relatively well maintained, largely residential, neighborhood in the northern suburbs. I have often been a member and initiator of neighborhood cleaning drives – each one of them failed primarily due to the impossible task of coordinating citizen action with the City Corporation. In my honest opinion and experience, blame for failure can be laid anywhere in the system, including citizen apathy, except with the much beleaguered Pourakarmikas. With the dual evils of an inefficient Corporation and a largely apathetic public, they are the only people soldiering every day to keep the city clean.  

If you crisscrossed our neighborhood you will not find a single garbage disposal area or bin. On the other hand, you will see, piles of garbage and leaves in street after street, in corners and in front of homes, in empty sites and abutting apartment blocks. The Corporation clears most of it in the morning but within no time, the garbage is back on and slowly piling upwards. That’s because there is no waste management system in place. A trip to the local temple necessitates walking past a mound of putrid garbage so high, I have often fled, in fear of swooning, straight into oncoming traffic. Confront the temple authorities to hear the same story of: how they have cleaned the area countless times but the Corporation does not institute a waste management system and, soon enough, everyone goes back to throwing garbage in that spot in no time.

Chennai does not have it half as good as Bangalore does. It is no surprise then that an Aunt has had the very same experience there as our temple. The area on the opposite side of her home in upmarket Adyar is leased by the government to a new age ashram. They do not maintain the premises and the surroundings have become a garbage disposal site. The family has personally cleaned the area at least five times in the past three years. In desperation, they have landscaped the pavement and planted trees and grass on the area. All to naught. Whoever was asked to cooperate turned aggressive on the old lady, the Corporation pleaded helplessness and things were back to the same mess in a week. The only job that the Corporation is efficient at, is to set fire to the garbage twice a month, in complete disregard of norms.  The air is filled with huge fumes of sickening odor, it is enough to make a young person take to bed. My aunt is in her seventies. In Bangalore or Chennai, nothing has changed on the ground.

I am sure every reader from India has similar experiences to relate and you will forgive, therefore, my angry frustration with what SBM is turning intoa big tent circus patronized by a tinsel obsessed media. How does a symbolic gesture of celebrity sweeping of the roads help sanitation!

·         60,000 crores/year – Combined (centre+state) allocation of Swachh Bharat Mission

·         69 million tonnes/ year – amount of urban garbage generated

·         6,000 tonnes/ day – amount of plastic left uncollected on the streets of our cities

 

What does the government need to do to enable us to invest in our own cities, communities and neighborhoods. Without wasting time reinventing the wheel, India and SBM must simply adopt Western models of urban sanitation and allow local enterprise to develop and deliver on the same.

A house cannot be cleaned without a broom, a dustpan and someplace to put the litter. Waste management and sanitation always fail on the last – a disposal system for litter. The list, collated below, emerges from countless hours wasted in grappling with solutions.  They are hard learned actionable points from the many failed attempts with the task of cleaning our neighborhood. Areas where government can spur participation with private enterprise are highlighted in blue.

The extraordinary mission of a Swachh Bharat is one that every Indian, across generations, has waited for. For long; much too very long. It is filled to the brim with great hope and is too important to fail. But, it will only taste success when the government is first armed with the political will to calculatedly invest in it for the long term. With the necessary infrastructure in place, the public will need little, if any, incentive to cooperate. After all who, in their right minds, does not want to have a clean and aesthetic environment to live in?

1.       Divide Waste Management into specific earmarked zones of operation – house, street, neighbourhood, ward and city

2.      Standardize garbage and commercial bags in higher grade recyclable plastic

3.      Outfit Paurakarmikas with a periodic supply of gloves , boots, dust aprons and masks. Incentivize their work. Coax neighbourhood associations to participate in incentivization programs for Paurakarmikas. Incentivize associations that deliver on citizen action and cooperation

4.      Mandate blue and green trash bins on the road outside each house or at the end of each road. Blue for recyclable waste and Green for wet and leaf waste. Tendered  dustbins to have a standardized design with sturdy body,  pedal operated lids and a sealable water outlet for cleaning

5.      Allot two tempo sized mini-trucks for each neighbourhood. Green tempo to clear the green dustbins. Blue tempo to clear the blue recyclable dustbins. Schedule collection on specific days and at specific times – preferably 4-6 AM to avoid traffic. Schedule pick-up frequency based on garbage production of each designated area

6.      Allot a separate truck for road/street-side waste. Wheelbarrows and small tempos to ride with the sweepers to collect the leaf/street-side waste

7.      Transfer to larger covered trucks in a ward collection facility

8.     Large clearly marked trash bins with standardized design to be deployed throughout the city. Distance between the dustbins to be no more than 100 feet. Each dustbin must be outfitted with a large plastic collection bag for easy and sanitary collection. Schedule frequent multi-hour pick-ups of city trash bins

9.      Transport to consolidated city collection centre. Collection centres to be equipped with Compactors for wet waste and Sorters for recyclable waste

10.  Load covered trucks with compacted waste to designated landfill

A Bull Fight In The Tamil Sangam

A little while ago, I was party to an exchange of opinions on Jallikattu with @realitycheckind – a fellow Twitter correspondent who is well read on social media for learned and incisive views on Indian Law and Policy. Jallikattu – a bull wrestling sport (not fight) – was recently banned by the Indian Supreme Court after a protracted campaign by animal rights activists. 

Where practiced, Jallikattu is considered culture; not sport. The storm of negative reportage about this cultural sport makes it easy to ignore its closeness to the hearts and culture of the local population. There are few reports (like this feature in the NYT) which penetrate the high-handedness of a culturally disconnected activism and attempt understanding. It is widely accepted that recorded reports of animal abuse are deviant manoeuvres which have recently crept into Jallikattu. As such, abuse could have been weeded out and a ban averted if activists had engaged instead of choosing a legal confrontation.

Realitycheckind sees the ban as predatory law that must be repealed. I agree with him on the peculiarly blinkered approach of both activism and the Law but, I nevertheless persist in my belief that a case exists for cultural evolution, for the continued existence of the sport sans abuse and, for responsible activism.

Re-reading AK Ramanujan’s ‘Poems of Love and War’ – a selection of his translations of Tamil Sangam poetry – I came upon a poem, from the Kallithokkai, on the Bull Fight which I have reproduced in full below. Jallikattu has traceable hoary antecedents and this poem belongs to the often quoted reference to a record of it in the Sangam literature. It is noteworthy that the poem describes the sport as a ‘bull fight’. However, verse after verse describes the wounded fighters as human with nary a mention of a wounded or killed bull. ‘Fight’ can thus be assumed to be an allusion to the battle of wits between a mighty bull and an unarmed man.  While the man risks his own life, the bull, at the end of the tussle, walks away defiant and unharmed. None of this is much different from how the sport is practiced to this day.

As to why the man indulges in this patently foolhardy exercise, Uruttiran, the author of the poem, suggests sexual selection at play. This dangerous display of machismo had an ulterior purpose as cultural ornamentation for a courting/mating ritual. “There, in the middle ground, where the brides wait, men gather again and again ready to master the bulls”. The men who were brave enough to enter the ring and tame the bull were highly prized suitors. “That bull is wilder than an elephant gone wild: do not loosen your hand’s grip on him, and the shoulders of our girl will bring you victory flags”.

Jallikattu still retains the machismo element and the winners, to this day, are able to enhance their value as suitors in the matrimonial game. But, the overt courtship rituals that it was associated with have disappeared. Women are still value seekers; it is what is valued as marriage-worthy that has changed and the game has kept pace with that change. It is this sort of evolution in the rules of the game, to stay au courant with the times, that will reinstate and refurbish an ancient culture.

A brief note on Tamil Sangam literature:

The period of the Tamil Sangam is dated between 200 BCE and 250 CE. The corpus of literature from this period is broadly classified into three broad groups: 1. Eight Anthologies of poetry – EttuThokkai 2. Ten long poems – PatthuPattu and 3. A book on grammar – TholkApiyam. Excluding the last, the other eighteen works contain within them a total of 2381 poems composed by 473 poets; 30 of who were women. The most prolific poet amongst them was Kapilar – 235 poems are ascribed to him. Of the women, AvvayyAr’s 59 poems command the highest pedestal.

An extraordinary feature of these poems is that all of them are collected under two clearly defined themes – Akam and Puram. Akam refers to the inner or personal life, deals overwhelmingly with love and sites its various moods in glorious descriptions of nature and landscape. Puram, on the other hand, refers to the outer or public life. Love doesn’t feature here; and when it does, it is not in the celebratory style of the Akam but takes on unrequited and perverse themes. All 2381 poems fall into one of these two categories. The poem that describes the Bull Fight is in the Kalithokkai - one of the eight anthologies. 

The Girl Friend Describes The Bull Fight

With the first rains

white clusters of the wild jasmine
backed by fresh thorn
are budding
on nodes once dry
in the cool rain lands.

The bud of the glory lily
looks like a ladle first,
the becomes a fire
when the red petals open
gathering the embers,
and its sways like a drunk.

The bilberry, flowering,
gives nothing but blue gems.

Weaving such blossom
in their wreaths,
cowherds vie with all they have,
enter the stalls
to let loose the bulls,
horns whittled sharp
as the Lord’s own pickaxes.

There, in the middle ground,
where the brides wait,
men gather
again and again
ready to master the bulls,
sounding like rumbling and thunder,
raising dust clouds, and smoke,
offer the right things
to the gods
in watering places,
under the banyan tree
and the ancient mango.

There, they leap into the field.

Look, the bull,
raised horns and skin tawny
as certain silkmoths,
he skewers to death
the cowherd who sprang
heedless of the look in the animal’s eyes,
carries the carcass high and shakes it
on his horns,

Like the warrior Bhima
making good his oath
sworn among enemies
cleaving the heart
of the man
who dared put a hand
to the tresses of his lovely wife.

Look at that black bull,
a moon-mark on his brow,
carry and shake the cowherd,
skewered and gutted
(the wreaths on his head
were flowers once on the caverned hills):

like the raging androgynous god
whose one half is His woman,
who dances at the end of time
when lives wear all their sorrows,
cleaves the heart of the Death-god
that rider of buffaloes
and feeds Death’s own guts
to His famished barbaric minions.

Look at that other bull
with spotted ears,
smooth reads
on his white body.
Teased by the fighters,
he throws that daredevil, that herdsman,
with the points of his horns,

like Asvatthama in grief and rage
not mindful of the darkness
whirling
on his shoulders
that eunuch who slew his father.

But now the herdsmen
play flutes,
good omens
for you and your man
wearing blue-gem bilberry flowers

[Saying this, the girlfriend went to the man and said: ]

That bull is wilder
than an elephant
gone wild:
do not loosen
your hand’s grip
on him,
and the shoulders of our girl
will bring you victory flags.

Only to that man
who takes on that murderous bull,
carries a staff on his shoulder
plays melancholy notes on his flute,
we will give our girl
with dark flowing hair.

Among men who take on a bull
no is equal to me, says he,
standing among the cows,
bragging of his power.

Surely, one day, not too far,
he will take us too:
for, looking at him
my left eye throbs,
which is a good omen.

There, the bulls are faint,
and the men have wounds all over.
The cowherd girls
with dark fragrant hair,
taking hints
from their herdsman-lovers,
move into the cool groves
of jasmine.

Uruttiran, Kalittokai 101

[Translated by AK Ramanujan in, ‘Poems of Love and War’ CUP, 1985]

 

 

 

A Public Health Emergency For All

This was meant to be posted yesterday but, the euphoria of Mangalyaan was so infectious that I decided to leave alone morose contemplations of health and disease for a little while. There is much too much that public health service delivery should learn from ISRO even if, the canvasses of space science and health are vastly different and make for tenuous comparison. Mangalyaan and ISRO’s success provoke the question of when (if ever) will health have its Mangalyaan moment? Perhaps, our comparative moment was with Pulse Polio. Perhaps too, euphoria moments are rare in health whatever the achievement. Unlike a World Cup or a Mangalyaan; with health, it is very hard to mobilise a sense of ‘us’, ‘community’ or ‘nation’. The subject seems to engage interest only when it makes a personal house call. Until then it is ever straitjacketed as the outsider other. This indifference is responsible for much health related crises irrespective of whether the sphere is public or personal. Almost universally, governments wake up to the huge price that must be paid for ignoring Health up and until the time when disaster hits. It is just such a situation – a tragic, devastating, and heart breaking crisis – that the West African nations of Liberia, Sierra Leone and Guinea face today with the latest Ebola outbreak. It is a crisis so grave that its spill-over consequences threaten the economic and social stability of these nations and their very future.

image

Yesterday, both CDC and the WHO released their modeled predictions for Ebola. The picture is expectedly bleak and both agencies stressed the imperative necessity of an immediate and all-out international response to control the epidemic.

Total number of cases in 2014 (CDC figures)

On 23rd September

5864 (3341 confirmed) Cases are spread over four countries; three of which are completely ravaged and overwhelmed

On 25th September

6263 (3487 confirmed)

Deaths

2811

2917

The total number of people reported to have the disease, in 2014 alone, is greater than the sum of all cases since 1976 when Ebola was first discovered in the DRC

More worryingly, the disease is seeming to grow exponentially with a doubling every three weeks – 47% of all deaths have occurred in the last month. Liberia, especially, is reeling with a 68% increase in the cases in just the past month

 

Prediction figures

Total number of cases by end September

21,000 (CDC)

Total number of cases by early November

20,000 (WHO) More conservative but agrees with CDC on overall long term projection

Total number of cases by mid-January

1.4 million (CDC)/ 500,000 to 1.4 million (WHO)

Public Health response to epidemics. Preparedness as response

A public health crisis of this kind – unexpected with devastating consequences – brings to fore the role of governments in the health of people. The poverty, poor social indicators of health, and inefficient health systems that exist in these African nations are prevalent in many other parts of the globe. Naturally, anxieties are high, world over, about preparedness and response in what really is a time of war for public health. In such a situation, the role of government narrows down to the swift execution of classic Disaster Response and Containment. An effective response strategy is executed with: a) the ready availability of a health force equipped with necessary tools for infection treatment and containment, b) a robust technological database that maps numbers and geography with necessary intervention and, c) a coordination force that links field staff with central command structures for effective exchange of information and response. 

Preparedness is the best response in a health crisis. A lesson India will do well to learn and implement.

But, can a government respond effectively in war when it has not equipped itself during peacetime? What is the level of preparedness that the Indian Government has in place? Peacetime public health interventions require an investment in preventive mechanisms, primary health and, health and sanitation literacy to pre-empt and curtail the spread of an infectious epidemic. A vital public health system should demonstrate:

1.    Adequacy of Healthcare Personnel – Our current Doctor to Patient ratio stands at: 1:1800 The WHO recommended ratios are: 1:1000. Even less airtime is given our acute shortage of nurses. In India, it is estimated that, to reach a Nurse to Patient of 1:500 we would need to shore up the number of nurses to around 2.4 million. There is a growing understanding that a significant amount of medicine and foundational healthcare can be delivered by para-medical training through ancillary academic programs. Such training will concentrate on a more practical hands-on-the-ground training with less of an emphasis on theoretical rigor.  At every level of health care delivery, whether primary generalist or tertiary specialist, nursing care is the most critical pivot around which containment and cure revolve. Degree certification in Rural Medicine and Nurse Practitioners aim to do just that and the government must institute them at the earliest. Not only will such a training empower local population; it will also provide a vital cultural connect to facilitate behavioral change.

2.    Regional/ District hospitals dedicated to Infectious Disease, Primary care, Maternal and child health and Prevention – Instead of setting up large tertiary centers and medical colleges in urban areas that compete with private enterprise; public health is better served by the ramping up mid-size district hospitals that are equipped to treat and respond to acute care. In the scenario of an outbreak, acute care entails early diagnosis, aggressive supportive therapy and isolation. The delay in the diagnosis of Ebola 2014 underscores the need for diagnostics on the ground. While remote tertiary centers can confirm the same with more sophisticated technology; immediate preventive measures can be kick-started on the ground. These nodal centers have great expertise with common and indolent chronic infections but need to be equipped and drill-prepared for more acute and unexpected scenarios.

3.    Training for all ancillary support staff in standardized supportive care and isolation protocols – Apart from training in supportive care, all healthcare personnel must have periodic training in methods of isolation, contact tracing and data recording. When this is enforced in the daily practice of medicine by doctors, training preparedness is easily scaled up on demand. The primary aim of all these measures is for containment to restrain an outbreak to as close as possible to its source. Our population density and 21st century mobility underline the importance of this vital step.

4.    Technology – Coordinated action is a vital part of health. Telecommunications, data and record keeping and telemedicine must link regional health centers with a centralized chain of command to oversee and coordinate. There are enough reasons for such an interlinking to be in place during peacetime. Reasons such as maternal and child health, malnourishment, tuberculosis and immunisation; all of which can benefit from a standardized and coordinated action. It is not just the technology that will be in place if crisis strikes; the work ethic of coordinated and cooperative team action with an adherence to protocols will also be ready to hit the ground running.

5.    Last but, perhaps, most important of all – Health literacy. This phrase has been in use in policy manuals and training modules for so long now that it might well have lost its meaning. The most critical aspect of health is the end-consumer. When that person at the bottom of every policy initiative is empowered with basic health and sanitation literacy, it is then, and only then, that vitally important behavior change can happen which in turn will ensure the effectiveness of public health measures. Without the cooperative involvement of the community, public health investment will continue to be good money down a long leaky drain.

Can Universal Health Coverage – a peacetime strategy – mitigate the consequences of an epidemic? Can it mitigate the spread of an epidemic? There is ample reason to believe it can. UHC is not an end-game. It is the strategy that opens up the door to more strategic allocation of government resources in health.

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In the NEJM’s special issue on Ebola; the President of the WHO writes on the critical role of poverty in the spread of disease through the poor and underdeveloped regions of the world. It is the nature of epidemics to strike first at groups that lack access, to health and to support factors grouped together under ‘social determinants of health’. Some of which are poverty, overcrowding, malnourishment, poor immunity due to other chronic debilitating diseases, poor access to water and sanitation and, illiteracy. Access to health, sanitation and literacy are the game changers in this cocktail. Armed with these, people have the necessary enterprise themselves, to equip for push back against the others.

Public Health Coverage does not only empower the poor. Critically, it also opens a window of opportunity for the government to streamline its engagement with health delivery – how much, in what and to what spread? In India, there is an extensive public health network that is  already in place. Much of it is poorly staffed and inefficient forcing people to choose private medicine with the burden of heavy out of pocket expenses. Rural Medicine and Nurse Practitioner certification will provide the necessary manpower.

With a focus trained on delivery of specific services, public health can concentrate its energies on foundational primary care, prevention mechanisms and health literacy. Further, mapping tertiary treatment to coverage in private centres (as is already underway with RSBY) will ensure access to all tiers of healthcare. Health insurance coverage must be made mandatory for the middle class and above. Both arms of Universal coverage will need strong government regulation and price controls.

For India’s health policy makers the Ebola epidemic is a critical wake-up call to review strategy for the way forward. In 1991, an economic crisis forced India to deregulate and push through reforms that were totally alien to the existent climate. Decisive, out of the box thinking at that crucial juncture put the Indian economy on a trajectory of growth and economic development. This is Health’s 1991 moment. A carpe diem moment to strategize for 21st century realities with the aim of creating a health system that is prepared and delivers.

Universal Health Coverage is the lead wagon on the new track.  The constant chatter of economics, investment, free markets and trade is jarring when there is no parallel movement on the critical sector of health. What will it take to get the Ministry of Finance to share space with the Ministry of Health? For our policy makers to comprehend that it only takes one wretched, measly little virus to bring the whole pack of glittering cards tumbling down. To comprehend that our health system needs an urgent revamp and needs it now.

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Supplementary information:

Atypical presentation of Ebola 2014

The current outbreak has two specific and distinct geographical clusters – one centred around three adjoining nations of Western Africa and the other, in the DRC (Democratic Republic of Congo). These two loci are sharply distinct with no traceable contact and have been declared to be separate and independent of each other.

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Ebola is a viral zoonotic disease. In other words, it is caused by a virus that is usually found in animals and which infects humans only upon transmission by direct or indirect contact with the animal. Fruit bats have been identified as the most likely reservoir source of the Ebola virus. The initial point of contact between bats and humans (whether it was single point of contact or multiple and if so, how) is not confirmed but suspicion strongly points to improper sanitization of bush-meat. Once Ebola takes root in a human, it can then spread from humans to humans through contact with the body fluids of the infected person. Therefore to contract the infection, one must necessarily be in contact with infected fluids like saliva, vomitus, blood etc. This makes the disease far less contagious than airborne viruses like influenza. Yet, its virulence and its rapid spread due to patient mobility is reflected in the high case fatality rate and the rising numbers of those infected.

The nations of Western Africa have not reported a single case of Ebola before this outbreak. The only known case from Cote d’Ivoire was in a vet who was infected while performing an autopsy on a chimp. He recovered and the disease ended its run in him. No other case has ever been recorded from the region. Further, the symptoms are very similar to two other diseases – Cholera and Lassa fever – both of which are endemic to the region. Naturally, it was these more common diseases that were initially suspected to be causative. With no prior experience with Ebola and with no sophisticated diagnostics on the ground, the crucial diagnosis was delayed for four months between the initial breakout in Dec 2013 and confirmation.

How are epidemics like this controlled? Ebola spreads by contact. So, the first measure is strict and comprehensive isolation. Isolation is the most effective method of containment of rare and rapidly spreading epidemics. With isolation, the virus is denied access to another host (an uninfected human body), terminates its life cycle in the infected patient and the infection’s spread is halted.

The other measure by which the infectious outbreak is controlled in the group is by raising immunity through vaccination. Responding to the urgency of the deadline many experimental drugs and vaccines are currently being rushed down the pipeline but it is an enormously difficult task to research, put through trial, and manufacture sufficient quantities of drug. Antiviral therapy is often seen as a magic bullet. It is not. The human body mounts an immune response against the virus. Shoring up the body’s natural defenses and treating the clinical consequences of Ebola (dehydration and electrolyte imbalance) with simple supportive therapy can make a big difference to the case fatality rate.

International Response

The national responses are creditable considering the prevailing circumstances of desperate poverty and inefficient heath systems in countries just recovering from debilitating economic consequences of protracted civil war. But the sum of many delays in diagnosis and the lack of a timely and coordinated international response have been costly. Also, the dissemination of information, in a calm and assured manner, on the importance of isolation and sanitation would have helped win public cooperation and support. Instead, there is now the additional burden of dealing with a fearful and restive public. A climate of mistrust, stigma and superstition has made many patients go underground and a large number of cases are unreported.

MSF deserves much credit for its stellar commitment to the ground task from the very beginning. In August, the WHO declared Ebola an International public health emergency and joined MSF in underscoring the need for urgent and immediate international aid. Significant action on this front has been the establishment of two global initiatives – the Global Health Security Agenda and UNMEER (UN Mission for Ebola Emergency Response). UNMEER has been called the greatest peacetime challenge that the UN will mobilize and for now is centered in Accra and will oversee an international coordination and mobilization effort from there. Established through a unanimous UN resolution on September 23rd; it speaks volumes of the urgency of the situation that an UNMEER team is already on the ground. The UN estimates $600 million as the cost for regaining control over the situation. Individual nations have lent assistance to the international and non-governmental organisations with ground health care workers and aid. India has around 45,000 of its citizens spread over the region and has lent an initial assistance of $500,000. Within the country; airport surveillance, quarantine and contact tracing have been engaged in high gear.

The governments of Sierra Leone and Liberia have repeatedly stressed the urgent need for health care personnel and beds. The NEJM reports that a facility treating 70 patients needs at least 250 health care workers. MSF has a current capacity of 180 beds in Liberia. They need at least 800-1000 more in that country alone.

The difficulty of mobilizing large scale hospital and isolation workers and equipment in a short time has prompted suggestions from the medical community to enlist those that have recovered as a volunteer task force. Another suggestion that has found less unanimous approval is mobilizing local society with training in home care as was done with the last century’s small pox epidemic. This dilemma for strategists is increasingly fait accompli for patients and their families. Treatment centers are overflowing with patients who can’t be treated because of an insufficient number of beds and healthcare workers. It is in this circumstance, of an overwhelmed health system operating in a climate of social unrest and fear, that homecare and home isolation is still being considered (despite its great risk of unmonitored isolation and supportive care) as a viable interim measure.

 

Paraphrasing Mr Mehta

For writers, the fashionable dictum of our times is: Keep it short and keep it simple. Fewer words, inclusive styles and conversational vocabulary are readability mantras that writers use as editing guidelines for the first draft. As with every evolution this journey too has many reasons; all satisfyingly, argument worthy. High on my list are the democratization of both writing and reading and, the end-of-century dominance of the ‘American way’ in all things life and living. After all, writability is hardly worth pursuing when the game is one of numbers and anti-anti elitism is the new exclusive club.

What came first is yet another chicken and egg conundrum. Did reading styles, that skim and speed read for take home points, devalue the exercise of crafting a good sentence? Or did the proliferation of writing, as wrap for a couple of readable comments, bring out our closet speed reader? However that argument resolves itself is not relevant to the generally accepted notion that much writing today is driven by the urge to opinionate, not interrogate. Ultimately, canonical faith needs to persuade in simple and familiar language if it wants to propagate belief.

“Never use abstract nouns when concrete ones will do. If you mean “More people died’ don’t say ‘Mortality rose’”. Famous pithy takes on writing like this quote from the redoubtable CS Lewis, are unfortunately used to make the case that words of more than seven to nine letters make for ponderous prose. It is true that deconstructing highfalutin concepts to comprehensible prose is a fundamental need for the popularization of academic subjects. It is equally true that simplistic prose in commentary cannot hope to stimulate anything more than simple thought. This is proven, without much effort, by the visible degeneration of Opinion columns to little more than, ‘have opinion will write’ drivel.

A writer who breaks this mould is Pratap Bhanu Mehta. His column in the Indian Express is a joy to read not only for the content of his thought, but also, for the style with which he articulates it. Almost every sentence manages the feat of being both scaffold for its kin and a stand alone quotable. His latest in the paper does not fail expectations. Writing on the flaws of the UPA as a cautionary tale for the new government; it is counsel that we would, each of us, do well to read and emulate in our own spheres of influence.

As tongue in cheek response to my own griping and as annoyed counter to a friend’s use of the word ‘pedant’, and also, with apologies to fans of new age wisdom; I have paraphrased his words to fit the standards of ready reckoner readability.

  1. Institutions sustain and enrich our lives. Whether in our personal and professional relationships or in our daily interaction with impersonal systems like the Law; it is worth remembering that each one of us is a cog in the wheel. We need to work on the wheel in order to make it turn and spin our way. Expectations always stand second in line behind responsibilities.
  2. It is more important to be credible than clever. Without the credibility of belief and/or action; argumentation, however cleverly spun, will fall flat.
  3. Plan for the long-term. The short-term is but a rung in the ladder that can be adjusted for height. You don’t have to win every battle. Let go of a few; but (and this is an important but) let go with the clear foresight of a purpose bigger than the moment.
  4. Confidence in self can degenerate, without warning, to intellectual sloth. Channel confidence to build credibility. Validation is a virtuous cycle.
  5. Nurture criticism without rancour. Without honest feedback, you are trapped in an echo chamber where all you will do is wither and fade.
  6. Communicate to get to power. Communicate to stay in power. Communicate to rise in power. In short; communicate. No one is born a mind-reader. Very few study to be mind readers and then, they often get it wrong.
  7. Never underestimate the power of error. Or, the power of others who will drum up your errors for their gain. A rise into grace is never as spectacular as a fall from it.

With this effort, I am assured that all clamour for dour, bulleted, get-to-the-chase prose is doused and that you, my dear reader, have fled this page to the delights of his own meticulously crafted one.