Do doctors not want to be doctors, anymore?

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Dr. Parthasarathy was a household name in Bangalore. A graduate of medicine from the pre-Independence days; he was what was then called an LMP – an early 20th CE version of the MBBS, expanded as a Licensed Medical Practitioner. He was a big man a little more than six feet tall; portly, had a ruddy complexion, dressed in tweeds and suspenders and always wore a tie. Oh, and a beret. Bangalore was an English cantonment town; its culture, lifestyle and entertainment was very Western (cosmopolitan they called it) and this sort of attire was quite commonplace for the time.

His office was on a tree lined but busy commercial avenue named for the trees whose sky framing canopy exists to this very day – the beautiful Sampige mara, or the Eastern Magnolia (Magnolia champaca). It was a tiny place with dark wood paneling the walls; a feature which, despite making everything feel boxed in, had an incongruous but comforting Harley Street ambience. There were wood partition screens with big blocks of carved wood for legs that divided the place into small cubby hole practice rooms. Some had eye-level ground glass panels with cut-glass green inserts and with inbuilt in-out slats. A totally unnecessary addition; considering that once he settled into his chair (he had no formal desk), his shoes would always poke out from underneath the partition. It was a wonder he managed to squeeze his frame into the small cubicle that had just enough space for making a quick half turn. I was small then and, to my miniature eyes, his office seemed like the inside of wooden chest. I can only imagine what the adults felt. Apart from this room, there was an examination room and in the back a compounder’s room with a small procedure table mounted against the wall. The entry had a waiting area with narrow benches along the wall that seated a quarter of the bum and on which you had to necessarily sit erect because if you stretched your legs you’d lock ankles with your equally ill and not a little irate neighbor. Shelves on the wall had an assortment of dusty magazines and comics that were never touched. Even if kids asked to look; scowling adults would ignore them.

The partitions between these rooms were themselves relics of another era. The interiors were always dark and a naked bulb or two would be left on even during the daytime . Their dim incandescence filtered through the gritty ground glass panels like fog, with a mysterious effect of clairvoyance. The partitions didn’t ride all the way up to the ceiling and so, every conversation behind them was well heard by all. No one made eye contact with the patient emerging from his very public, but separated, meeting with the doctor. All screams and groans were equally communal. Our anxiety and their noise rose in harmonious concord. Children invariably started crying and harassed parents would run out into the welcome distractions of the street. Across from a side door there was a tiny alleyway that led to a pharmacy – ‘Famous Drug House’. And on the other side was a bakery that had wonderful smelling bread. We never got to taste it, since the only reason we were there was if one of us was ill and any attempt to opportune the elders for ‘bakery’ goods at such a time would be rebuffed. We were left to indulge our longing stares and smell the air. The clinic’s interiors and the bakery aroma gave fever induced deliriums a welcome respite. There was no reception, no pesky counters, no fussy data recorders and no fancy gadgets. Just a big jolly doctor with a big heart and what looked like a giant stethoscope. There were also some painful glass syringes in the back with the compounder but that’s a side story.

Sitting in his office it felt like 1840; you could almost hear the horse carriages rattling over cobble-stoned paths and the horses harrumphing outside. That he could create this ambiance in a busy thoroughfare in the heart of a bustling neighborhood is testament to the man himself. I often wondered if it was our overactive imagination fed on English children’s books that made us think so; but, no. I am quite certain that most others’ reminiscences would be along these lines. Maybe it was another figment of my imagination but, every person who emerged from that cubicle would have a look of lighthearted relief. The good doctor would’ve dissipated their anxiety and all that was left was the minor matter of the physical ailment for which he’d have armed them with bolstering words of courage, a prescript for some medicine and a recommendation to sample the bread with very hot milk and a generous sprinkling of sugar. After which, he would boom over the partition – ‘next’ – and we would make way for the next sufferer in line, impatiently waiting our turn for his magic.

He practiced there, in that same place, for sixty five years. Maybe, more. Every day he would open shop at the same time. On time, every time until his very last day. Retire home for a siesta and return with renewed vigor in the evening. For a staggering number of years, well into the nineties; he unfailingly followed this same routine. William James would’ve been proud. Do I hear you say, fees? I remember a board outside that said two Rupees per consult. There was a box by the side of the door in which the fees were to be dropped. Many would plead inability to pay that and he would never protest. I remember him locking up one late evening when my father and I hurried to catch him; and I remember too, the jolly gusto with which he unlocked the big padlock and took us in. He silenced our fervent apologies by ordering hot almond milk from the bakery; astutely remarking that I was without the mindful escort of my mother. A liberty he would never have accorded himself in her presence. A secret delight, he knew I could only sample this way.

This was the doctor figure of our growing years. The one we modeled our ambitions around.  The one we wanted to be when we grew up. The one we tried to emulate. And yet, here we are today with a measure of the heart perhaps but with not a spot of the persona; that even the most generous would fail in making a favorable comparison.

So, what changed and why? Of course the practice method itself is vastly different. Complex technologies have come to dominate our science. Today, a doctor wouldn’t be able to stay financially viable with a practice like that. The business of medicine and health has become so huge; it has come to occupy a permanent fixture in our lives. No more do people go to see the doctor for the occasional times when they are ill. It is now commonplace routine to go when well in order to be told that all is well. This change has been talked and discussed ad nauseum with so many different points of view. What is less talked about; is how the humans, in medicine and running it, have changed.

A doctor was seen as a member, a necessary and vital part, of a community. Neither the community nor the doctor saw themselves as separate entities, distinct from each other. Medicine was a social profession. As such, most doctors were sociable and social beings. They ‘liked’ interacting with the community. They thrived on it; they actively sought it. A good portion of their knowledge was also empirical. It came equally from listening, observing, communicating; none of which was possible without spending time with people. Less time was spent maintaining records; more in conversation with the patient. By doing so, they consigned to memory their patients’ stories which, for them, was the best record of all. For doctors like Dr Parthasarathy, it was about the people. He and his tribe saw themselves first as pillars of the community and as healers only after.

Today’s doctors are vastly different. Though the patient load is frequently blamed for the change; it was more the explosive invasion of technology that fueled it. The much talked of thoughtful lateral shift, that incorporated the old ways into the new, did not happen. Almost overnight, these grand viziers of health were cast overboard and the new, technology and drug driven medicine, moved into its place. The change happened right under our noses; but sadly, the regulatory bodies did not have the muscle or the will to stem the tide and give it direction. As each machine made more exquisite diagnosis and after books became tomes of data, doctors had little choice but to submit to the constraints of time bound learning of both text and technology. Slowly they receded into the great buildings with sharp white lights and chemical odors of sanitation, behind reception desks and complicated registration procedures, behind payments and reimbursements and behind monitors and data screens. The simple human interaction of eye contact, a smile, a warm handshake, a comforting word or two, a shared experience, – qualities that are so ordinary they ought not to be an expectation – these same qualities slowly ceded space to the mechanized takeover of electronic systems and the creation of a health industry. Where medicine was once about community and its people; it now became a single minded pursuit in the excellence of the self. More degrees, more accreditations, more gizmos, more procedures, more papers and more zonal dress codes. A series of layers, each taking the doctor farther away from his primary interest – the community and the patient. Patients thus morphed into bodies, into data, diseases, symptoms, signs and a diagnosis. The tortured anxiety of a patient’s eyes became unrecognizable to the tortured anxiety of the doctor’s pressure to stay in the game. For both, the interaction has become a discontented trek to nowhere.

We could retrace our steps in time to some extent by empowering Primary Care Physicians and Family Medicine Specialists. It would require easing of the controls over these fields and making them competitive by increasing reimbursement to these practitioners. By making Primary Care a profession of choice we give ourselves a second chance at rebuilding health delivery to a standard of care that only a synergy of both the art and science of medicine can bring. However, policy change is so slow in comparison with the speed of technological advancement that by the time this decision is implemented, it will probably take a form very different from the one that is currently envisaged.

The flipside of all this is that it might only be a couple of generations that feel this angst. Doctors and medicine have only changed in lockstep with a rapidly evolving societal dynamic. A new generation is turning the corner; those brought up on technology, whose daily life is ruled by it and who therefore don’t expect much different from their doctors. To this group; the contradiction of doctors morphing into hi-tech health industry technicians might not matter as much. At that point in the future; will we still want empathy and the personal touch from our doctors, or will we settle for technical prowess and peer ratings. With doctors on track to becoming service providers, and in the absence of investment in primary care, the gaps of the heart will probably be plugged by resources like social networks and patient communities. The last especially holds great promise as a bridge between a physician’s sterile prescription and the actual life tools for sustaining cure and for balancing illness with a quality of life.

Maybe, by then, a doctor will cease to embody our nostalgia for empathetic care. Perhaps, a name change will come about and we will call ourselves something more in keeping with the time. And roses will no longer be roses and their smells no longer as sweet.

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Daybreak

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The Sun recesses
Always in a violent fury
The drama of a finale
A final attack on submissive Sky
The end, we think
Clap and retreat.

But recouped she returns
A new assault on forgiving Night
Seeks and wakens in evil glee
Her might recording, ‘Still living’.
A protest sounds a triumphant discord,
‘Living still’.

Does India have the highest Child Mortality Rate or did the Media get it totally wrong?

A little less than a week back; Indians woke to yet another screaming headline and ‘breaking news’ story from the media. Every major news outlet (as can be seen in the link) carried the story in bold print. This one was truly alarming – that the latest Unicef report had cited India as having the highest Child Mortality Rate in the world. After the initial horror and dejection waned, and ceded ground to the next horrible thing to hit us, the story continued to gnaw at common understanding of ground realities. Despite the fact that India does have some truly bad public health data; there are still countries doing far worse than us and to have surpassed them all, implied a splendid surge of negative performance that even we, would have struggled to achieve.

Reading the report reveals a complete misreading of the data by the media with the expected misinterpretations. The Unicef report contains no such data, as publicized, and neither has any international publication mirrored the domestic media reports. This then was the over-eager Indian media skewering our reputation in its enthusiasm to be the Ur-harbinger of bad news. Attempts to get them to correct the narrative have fallen on deaf ears (emails and tweets) and this post is written with the hope of correcting the glaring discrepancies in the reportage.

[Pic courtesy: www.indiacsr.in]

No, India does not have the highest child mortality rate. We have the highest number of children that die under the age of five; that number is reflective of the size of our population. A distinction must be made between the total number of children that die under the age of five and the child mortality rate. Since these are two totally different things; it is important to lay bare the difference. While doing so, no attempt is being made to diminish, minimize or molly coddle the appalling figures. For a country with high ambitions of economic superpower-dom and that is called an ’emerging market economy’; these figures are, plain and simple, unacceptable.

To get at the ‘hows and whys’ behind these dismal figures; we must first separate Infant Mortality Rate (IMR) from the Under-five Mortality Rate (U5MR). Causation is different in these two categories. Mortality Rate (MR) refers to the number of children that die per 1000 births. IMR refers to the number of children that die under the age of one. U5MR refers to ALL children who die under the age of five and therefore incorporates IMR figures within it.

U5MR declines globally at a higher rate than IMR. It is far more difficult to grapple with IMR. These are the figures: globally, IMR has low rates of decline: 32% in the past two decades and an annual decline of 1.8%. Compare this with U5MR that, for the same period, records 41% and an annual decline of 2.5%. For South Asia and India, IMR contributes more than 50% to the U5MR figures. And India, independently, contributes 30% to the global IMR. It would be more appropriate therefore to address U5MR as the sum of its two individual components – IMR (birth – 1 year) and CMR (Child Mortality Rate of children between 1 and 5 years). These two categories are very different beasts. The determinants, causation variables and policy outcomes are different and varied in both.

1. CMR operates at a macro-level, is relatively homogeneous and is more easily subject to criteria like access and affordability. These factors make it amenable to standard policy measure that are easy to implement across different strata of experience. Effective and determined deployment of vaccination and access to: safe drinking water, sanitation and basic health facilities significantly alter CMR figures. That we haven’t been able to tackle this component of U5MR is indeed a matter of poor governance. The appalling figures clearly reflect the deficiencies in the drafting and implementation of policy.

2. IMR, on the other hand, is in an entirely different category. IMR is not as readily subject to simple health economics and is strongly affected by culture and gender; two variables that are difficult to regulate by policy alone. It is heterogeneous and operates at the micro-conditional situation of family, individual and communities. The ‘pre-term and post-term causes’ listed in the report, are variables that impact IMR. IMR reflects on both mother and child and is affected by a culture-spread that extends from the treatment of women in a society, to prenatal attention, to delivery/obstetric practices and finally to the postnatal period. Gender discrimination and cultural handling of birth (breast feeding, cord management, etc.,) factor directly into IMR. Health information dissemination and reform of cultural norms have to be critical compositional elements of any policy that targets IMR. To deliver on outcomes through the maze of socio-cultural barriers is not easy and when the deeply diverse nature of our myriad cultures is factored in, it seems a nigh impossible task. Yet, if we invest our collective energies and efforts on effectively tackling IMR, the rewards will accrue on multiple levels, since this one factor encompasses mother, child and all in between.

U5MR data analysis: (figures are from the report)

1. Sierra Leone has the highest U5MR in the world. 185 children die per 1000 live births. Twenty nations have UFMR higher than 100. Of these, nineteen are in Sub-Saharan Africa and one outside Africa, in Asia – Afghanistan. Afghanistan has a U5MR of 101

2. Comparison of Sub-Saharan Africa and South Asia:

a. Sub-Saharan Africa has a higher U5MR than South Asia (1 in 9 as compared with 1 in 15 for the latter. To understand how appallingly bad these figures actually are – in industrialized nations, the ratio is 1 in 167)

b. But, the rate of decline is faster in Sub-Saharan Africa than in South Asia; an encouraging trend for them

c. As of current figures however; a child born in Sub-Saharan Africa still has a 1.8 times greater probability of dying than a child born in South Asia

3. 50% of the ‘total number’ of child deaths (not a rate; but a number) occurred in five countries – India, Nigeria, DRC, Pakistan and China. In *this category, India clocked 24% and was highest

4. A quick comparison U5MR in countries: Sierra Leone 185/ Afghanistan 101. India – 61, Nigeria – 124, DRC – 168, Pakistan – 72, China – 15

GM Crop (Bt Cotton in particular) – Good for India?

This is a rushed response to an article that appeared in Live Mint on ‘why India needs GM foods’  http://www.livemint.com/Opinion/rsIyj8Q63d01GUSdVtXiCI/India-needs-GM-food-crops-to-boost-agriculture-productivity.html

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My comments are restricted to this article per se and not to the larger issue of GM foods. Apart from making a limited point. There are different categories of GM foods. There is genetic engineering of seeds to increase business and productivity and there is the fortification of foods to improve nutrition. Clearly two very different things. Most engineered foods, currently on shelves, belong to the latter category. Also, it is imperative that GM foods of any kind must be labeled. That, is a consumer’s right.

As regards the article: Let me sum the argument for you – The government fails the farmer by not providing him access to irrigation and capital. He is made to buy a seed that is more expensive on the promise that it increases productivity and return – it does not; except perhaps in the initial years. It needs more water – they already have no water! The much acclaimed pest resistance is not so true after all; a fact, the company itself admits to. It is not giving them a return on investment. Has pushed the farmer to debt that in turn forced him to suicide. Yet, the authors address a correlation/causation disconnect, by suggesting that the fault lies not with the seed but with an inadequacy of irrigation and to further increase lending to the farmer. With what hope of recovery in a scenario such as this, wherein the expensive seed requires more water than available and is already becoming pest resistant entailing renewed investment in pesticide?

Bt does not stand for Biotechnology. It is the name of the bacterium that is incorporated into the cotton seed in order that the plant is resistant to the Bollworm pest. The seed is called Bollgard1. Productivity and yield increase because of reduced pest affliction and low pesticide use. Well, guess what? The Bollgard1, as the seed is called, developed resistance to pests; the seed failed, the pesticide use increased and now, Monsanto is pushing Bollgard 2!!

1. If the problem is not the seed and is inadequate irrigation and finance as the authors state; isn’t it simply obvious that where such infrastructural deficiencies exist; they should first be dealt with first by the government before threatening the fault lines of a precarious situation with the introduction of an expensive seed. Assuming they (the government, that is) are not complete imbeciles; why then did they do it? Because the seed was supposed to enhance productivity and better returns, DESPITE these problems. The experience however has not held up the claim. Incidentally, early recommendations to use it in water rich areas were ignored and the seed was widely pushed all over the land.

2. How do we know that the old version seeds (‘natural’ in quotes in the article) would not give the farmer, the benefits of increased productivity and return, once the infrastructural problems of irrigation and capital were tackled. Also, the Cotton Corporation of India has published data to show equal/better performance by the older seeds. Ideally a double blinded study must be conducted after eliminating such variables to ensure belief in new technology. Bt cotton was initially meant to be used only in well irrigated areas. Typically, Bt cotton, in the first few years after planting, gives a good yield. Subsequent years are unable to match the initial euphoria and the inherently high costs of Bt cotton start to pinch. Stagnation productivity and yield drag have been widely documented. In Gujarat too. Resistance to both primary and secondary species is considered the reason for this pattern

3. Equating GM foods to tractors and better farming techniques is clearly said for effect and can be set aside. The problem with GM foods is largely due to concerns with biosafety and unsatisfactory outcomes. Biotechnology in food suffers from information gaps that industry typically refuses to address and works back channels instead to force the population to accept measures that translate into profits for business. There is nothing wrong with profit making as long as the farmer is benefiting too. The misinformation spreads when reports such as the results of the field trials have not yet been made public. Another common misconception, this one unfair to industry, is that Bt cotton contains the terminator gene. It does not.

4. Ideology hardly matters when Mr Acharia chaired a committee that produced a report and that committee comprised people and experts across the spectrum of political and scientific belief.

5. Finally, the policies of the government are clearly an abject failure. The government has failed its peasantry critically with the dissemination of information and the regulation. Yet, it is hard to put down the committee recommendations for the cessation of field trials as unreasonable. In any case; a release of the data from earlier trials and a better analysis of a complex subject like biotechnology, that includes scientists, will serve to widen the debate and plug information loopholes. Indeed, as the authors opening lines state; those that are anti-bt are, perhaps, those that understand it best.

GM foods, like nuclear power, are technologies of last resort that we might will have to accept faced as we are with ever burgeoning numbers that need to be fed. It stands to reason therefore that policy must be approached with a long term view that benefits the human race and our ecology; rather than the short term industry-favoring measures that we have seen until now. More critical policy change, in the irrigation and public distribution systems for food, must be effected before GM food can be given a fighting chance at a fair trial.