Arbitrary Powers

Today there were two interesting bits of news that were reported from Kolkata and London which focused on negligence in the health and social services and corrective executive action. The first article was about a visit by the new Chief Minister of West Bengal, Ms. Mamata Banerjee to a hospital as an inspection tour and her confrontation with the hospital director who did not take kindly to the unannounced visit. Then the second article was about Ed Balls (the then Health Secretary of State for Children, Schools and Families in the UK) sacking the local head of Child Services publicly in 2008 over the death of a 17 month old boy. Subsequently, the court has agreed that the action was unlawful.

Although the Bengal story may not have ended, it seems to be on the same path as the British incident. The two stories converge in the fact that the top political executives view the bureaucrats as guilty parties straight away and by exorcising these personnel from the system, they hope to make things right. And in a naive sense, they do establish their authority and potency but fail to really create a tangible difference. In the British case, there is talk of suing for damages which will act as a deterrent to the government. But in Bengal, on the back of a game changing election, there is little to check the actions of the executive.

After the Left government was defeated in West Bengal, Ms. Banerjee has taken over the reigns and is learning the ropes of direct power. And she started out by doing what Mr. Chandrababu in Andhra Pradesh and Ms. Jayalalitha in Tamil Nadu did when they were previously Chief Ministers. She is hitting on the obvious targets first by launching an inquisition against the people manning the system. That move, although popular, may not be the best advised route since both Babu and Jayalalitha lost in the subsequent elections from a government employee-led backlash. But more than just the political fallout of finding fault with the system, the chief executives have to realize the value in being correct in what they do, both popularly and legally or risk the non-cooperation of their subordinates who will throw the book at new initiatives.

Links:
1. http://www.mumbaimirror.com/article/3/20110527201105270336326472fc7cba1/Didi%E2%80%99s-hospital-visit-sparks-%E2%80%98sick%E2%80%99-wordy-duel-with-boss.html
2. http://www.guardian.co.uk/society/2011/may/27/sharon-shoesmith-court-win-baby-p

No Favor

The state of Assam in India is about to assign healthcare as a basic right for its residents. The matter is not voted on yet but the papers seem to hint that this bill will soon be law. This is a first for India and it will open the floodgates which will force the rest of the states to follow suit. The skepticism regarding feasibility and the more sinister search for the benefactors kept aside, this is a brave piece of legislation which will lead to some good.

The government in the state in pursuit of whatever political mileage points has taken up the burden of affording its citizens access to some form of public healthcare. Mind you, they are doing no one any favors. Under Article 47 of the Constitution of India's Directive Principles of State Policy the state is required to do exactly this:

Article 47:
"The State shall regard the raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties... "

There are other such Directive Principles in that document which are equally revealing about the state's responsibilities, a pity that none of them are binding on the state. No court can force them to do the right thing, for that they have to grow a conscience and by 'they' I also mean we.

All the legislators everywhere are really our mouthpieces, its called upward delegation in a democracy. They play a game where they try to guess what would please us and go about doing it - like a child would in trying to impress a parent. When the game gets too hard and it becomes difficult to ascertain public taste or mood some get distracted and go and do what politicians are cursed for doing.

But once in a while they get their act together and either by accident or plan actually do their job of lawmaking diligently. And when they do, it is important to note that these lawmakers are only an instrument of enforcing public will, nothing more. So acknowledge their contributions but there is no need to feel grateful.


Link:
http://timesofindia.indiatimes.com/india/In-a-first-Assam-to-guarantee-right-to-health/articleshow/5673849.cms

Nobel Prize for Elocution

Barack Obama won the Nobel Peace Prize today. I guess being the President of the Untied States is a gift that keeps giving. Only, with this prize there is the small matter of the $1.4 million prize money. I am not sure if the President is allowed to keep the sum under their constitution but that is a different matter. What every news report did harp on is that the committee has this year used the prize as a carrot thrown at the world's most powerful man and what remains to be seen is if the bite is as strong as the bark (in matters of peace, ofcourse).

The use of persuasion is not alien to Mr. Obama (see previous post: 'The Spoken Word'), indeed he arguably is the most persuasive man on the planet. And therefore he surely understands the intention of the world through this prize to hold some form of minute influence over his country's actions through him. America being the sole superpower, the world needs to be reassured that reason does prevail in Washington. Indeed, the president has acknowledged that the honor is an encouragement for his stated international policies - implying that it is more a 'Thank God!' for the end of the Bush Doctrine and not so much a nod to his own achievements.

As America debates a very domestic issue of Healthcare Reforms, where the president seems to be on the ropes, this prize has come as a welcome relief to his credibility. And although it may have no bearing on the outcome of the Healthcare reforms, Mr. Barack Obama could yet realize the goals of the Peace Prize through these reforms too. Any change in Healthcare delivery system in US will have knock on effect on similar systems around the globe. The world is in need of cheaper drugs which is possible when some of the drug patents are relaxed in the US. Also the USFDA is the standard bearer for new drug developments worldwide and hence any sharing of expertise and knowledge with emerging nations can only help saving lives.

Often though the public fails to see in times of change, the things that remain the same. On the ground therefore the winner of the Nobel Peace Prize of the year remains the head of the army which is at war in two foreign nations. Picking holes in the choice almost seems too easy. Yet, what the award this year succeeds in doing is shedding light on the kind of leadership to be desired from heads of state. To world leaders, this announcement hopes to show that the power they hold can be used for more than simply furthering narrow national interests and asks of them to be true statesmen of wisdom if not merely the right words.

More Reading:
1.http://www.huffingtonpost.com/david-wallechinsky/obama-awarded-nobel-peace_b_315111.html
2.http://www.telegraph.co.uk/news/worldnews/northamerica/usa/barackobama/6284763/Barack-Obama-surprised-and-humbled-by-Nobel-Peace-Prize.html
3.http://gregmankiw.blogspot.com/2009/10/first-year-grad-student-wins-nobel.html

1 every 1.4 million

A good friend and doctor once narrated a story about a neighbor, a young boy who contracted Polio after being vaccinated. He went on to explain, in a matter of fact manner that in some rare cases the small dose of the virus that is used for vaccination is enough for a few people to be stricken with polio. This he knew from what he was taught in medical school. But he reassured all the intent listeners to yet another of his medical nightmare stories, that this was a far off shot with the probability being something like one in a million. The discussion then moved on.

Most people around the world today are vaccinated for a number of diseases and with good reason. Vaccination has dramatically reduced the infant mortality rate around the world and has been the main cause for the reduction in new cases of mental and physical disabilities. In India, vaccination is an ongoing drive, a mission which mobilizes large armies of doctors, nurses and resources with the objective of eradicating diseases which much of the world has already conquered. Actors and sportsmen are roped in to promote the vaccination drive. The government machinery visibility at these drives is next only to the general elections. A successful series of drives means that a generation is saved from the scourge of disease. Almost everybody is satisfied. Almost.

Coming back to earlier story of the boy. His condition is known as Vaccine Associated Paralytic Poliomyelitis(VAPP) and the statistics from the US show that the risk of VAPP is 1 case in 1.4 million first doses (according to Brown University [1]). It might be true that without the Oral Polio Vaccination the boy might well be jumping and kicking like most other kids of his age today. In his eyes, he has paid the price for a society to achieve its ambition. And as my friend had assured me, this is a risk that is considered 'acceptable'.

Utilitarianism and Medical Ethics

In other words, the gamble (for lack of a more potent word) for the government is laid out with the odds in favor being 1.4 million to 1. Odds which the Government of India through its Pulse Polio Campaign seems to have enthusiastically embraced since 1994. But the question remains, is it the government's role to gamble, especially with people's lives? The argument for such immunization campaigns have their origins in Utilitarianism; when the sum of all the benefits outweigh the losses that are incurred then such actions are acceptable. I suspect this is the same 'acceptable' as the medical literature prescribes in the previous paragraph.

I am sure that the subject of Medical Ethics is teeming with such predicaments. The profession of medicine dictates a certain disconnect from such philosophical issues for effective delivery of care. But it is important to note that these tough questions remain to be answered at some point and with some conviction. To attempt to answer these issues, the society and therefore the government have to reach a consensus on how to tackle such difficult matters. Thus the bargain for a better life for most (if not all) might lead to sacrifices by a few. These sacrifices might be voluntary or forced. A government or society functions because certain liberties of the citizens are withheld and controlled by it. A democracy conceals this fact better than any other form of government. In this regard, the politics of medical ethics is no different from politics in general.

The Solution

But as with everything else in a nation such as India (as opposed to say China), a sense of dharma somehow prevails even in the most difficult of moral decisions. In the case of Vaccination Campaigns, the solution has always been presented along with the question: Pulse Polio Vaccination in India is Voluntary. Therefore the gamble is passed on by the government/society to the parents - the people with the most to gain or lose and hence the apt decision makers.




Interesting Reading:

1. http://www.brown.edu/Courses/Bio_160/Projects2000/Polio/PoliovirusVAPP.htm
2. http://mutiny.in/2008/04/25/dangers-of-polio-vaccination/
3. medind.nic.in/ibv/t05/i6/ibvt05i6p571.pdf
4. http://timesofindia.indiatimes.com/Chennai/Rumours_on_pulse_polio_deaths_spark_violence/articleshow/3871494.cms
   
5. http://timesofindia.indiatimes.com/Bangalore/Schoolkids_used_in_polio_campaign/articleshow/4060813.cms
   
6. http://www.hindu.com/2009/02/01/stories/2009020155070700.htm
   
7. http://en.wikipedia.org/wiki/Medical_ethics
8. http://en.wikipedia.org/wiki/Utilitarianism

Healthcare and Livelihood in India

Healthcare and livelihood are connected. When a government has to look at healthcare, it is bound to look at effects on livelihoods. In India where most people fend for themselves when it comes to healthcare, the causality between health expenses and livelihoods is most obvious to the patients and their families. The country does not have a great national healthcare system to guarantee the citizens at least basic care when in distress. This is more acute in the rural hinterlands of India, in fact most of India functions as it always had when it comes to issues of health and sanitation. A degree of inevitability and fate has built up in the minds of the population which combines with a sense of karma which is the anesthesia for all the nation's troubles. Hence the calls for improvement in healthcare is the last issue on anyone's agenda. This is evident when the budgetary allocation for healthcare is a meager 1.3%. It is easier for all to overlook the deficits in healthcare as matters that are political in nature.

With all the troubles in healthcare in India, the question of livelihood are not comprehended or at best ignored. For the vast majority for whom survival is subsistence, any damage to health will lead to loss of income which combines with the absence of savings lead to consequences which go beyond mere healthcare. In fact this inability to sustain through treatment or even the mere knowledge of this possible plight changes the psyche and therefore the behavior of a large parts of the population.

Right vs Responsibility

In the recent US elections the two presidential candidates were asked to state there view of how healthcare should function. Barack Obama said Healthcare is the Right of every citizen while John McCain saw it as the responsibility of every citizen. The Right vs Responsibility debate is at the crux of healthcare. The big pieces such as Government, Drug Companies, Medical Fraternity, Health Insurance providers etc can only fit into place when the choice or balance between Right vs Responsibility is understood.

First, if we look at the 'Right' side of the debate. Healthcare as a basic right of the citizens is a position that can only be possible when there is a government in place to ensure and carry out the right. In fact all the rights written into constitutions need guardians to enforce them, without these guardians these rights become hollow promises. Hence the role of the government increases when healthcare is seen as a right. When the mantle of healthcare then falls on the government, the complications might be many but what is for sure is that in the eyes of the law, every citizen is entitled to healthcare.

With India being a country of limited resources, its not a surprise that health has been a subject of the government. And just as other resource allocation schemes undertaken by the government such as Public Distribution Schemes (PDS), healthcare has also been on a path that leads to nowhere. This is understandable since it is unfair to expect one sector, even if it is as critical as health to be treated different from any other by the government, be it in efficiency or effectiveness. Therefore as a right, healthcare will only improve along with the performance of the government if it is left alone as a right.

But when healthcare is looked at as a responsibility of the citizen, then there is a huge difference in the outlook. With the responsibility shifted to the beneficiary of healthcare, so does the burden of the means to provide the service. As healthcare becomes a service commodity with the laws of supply and demand being applicable, the role of the government becomes that of a watchdog while the role of the Drug Companies, Hospitals, Insurance providers increases. But the biggest change in role is that of the beneficiary of healthcare as he ceases to be a beneficiary and becomes a consumer of health services. And if we are of the inclination that market economy will find its way, then eventually people will start to work towards providing for their health costs just as they provide for their other expenses.

Here again the scenario in India is such that for a section of the population healthcare from birth to death is a responsibility because of the inadequate heath facilities that they can access through their rights. This a sign of the stratification of the society in terms of education and wealth. The government too welcomes any move away from the 'right' notion as that removes the direct burden on it. But the fact remains that when a section of the nation cannot afford to carry their own cost of treatment and if healthcare is continued to be seen as a responsibility then the government will have to share their burden. Thus subsidizing healthcare for some, but not lowering the quality.

Thus, India presents a case where healthcare both as a right or a responsibility will work.By not choosing either one of the means of focusing on the problem there is a risk that there is a lack of the sense of direction to the efforts and hence the risk of ultimately wasting resources and lives because of a lack of unified perspective on the problem. But as the target is to first get everyone under either one of these umbrellas before shuffling around or opting for one, a change of course will itself bring huge costs.