Beginning from early Egyptian references of tumours in the breast that are choicelessly left untouched to the golden era of surgery when the scalpel was wieleded as a panacea for any bodily growth, the book presents a few thousand years of journey towards our romance with the miracles of modern medicine and the eventual disappointment that was to come after.

Doctors often do not write, canning their life experiences into a pressure cooker that is often let off on their wives or their families. If and when they choose to let the steam out as literature (and assuming that they have what it takes), the product is often wonderful. Highly recommended for doctors, highly recommended for patients (past, present and future) and the only reason not to read it would be if it is not published in a language you can read.

I was myself reminded of a photo I took from Crossword, where his oft-quoted book on famines “Everybody loves a good drought” was (perhaps?) inadvertantly placed under “Indian Fiction”, when he spoke about the time when he was invited to talk on “Indian fiction” on one of his foreign trips which he accepted for he was an authority on the Government documents.

Sainath started in earnest with the rise in petrol prices and deftly manoevered that to a paragraph he read out from a few sheets of scribbled stuff he had brought to the podium. He reassured us that this is not what he often does – read a prepared text. It was from the budget speech of 24th July 1991, when the present prime minister, Manmohan Singh was the finance minister. We got to know this only later though because the context around which “liberalisation” was brought in still exists today….at least for most of rural India. Sainath reminded us that line “…Budgetary subsidies, with questionable social and economic impact, have been allowed to grow to an alarming extent”. Since then, how many such “subsides” have had great impacts?

It appears that such “subsidies” are available for all to see as an inconspicuous annexure to all budgets – “Statement of Revenue foregone” – here it is for 2009-10. This document lists the special tax exemptions and concessions given to individuals and corporates and calculates the revenue ‘lost’ or foregone by the central government as a result of these. The figure is somewhere near 35,000 crore rupees – Sainath reminded us that this is around the money it takes to run the entire NREGA programme for a year – yes, that is what was “foregone” – the new word for corporate subsidy which has now replaced those budgetary subsidies of pre-90s days which had questionable social impact! This foregone revenue is climbing year after year and one of its greatest components has been the custom subsidies. And for those of us who were wondering if our good government was keeping the interests of many of us in mind while it was perhaps waiving off taxes on essential drugs, here is  the list – precious stones and jewellery, mineral fuels and oils, animal or vegetable fats, machinery and electrical machinery. The first one in this list – a Rs 48,798 crore exemption on customs duty for imported jewellery in one year alone – nearly the size of our entire annual food subsidy all for the great drain robbery.

Indian has more billionaires than all Scandinavian countries put together! And this is not merely from the richest cities, we were told. Sainath described those nice weddings in rural India particularly those of Gadkari’s son held in Vidarbha – that place where farmers are killing themselves for debt. Seems a bit exaggerated right – why would farmers kill themselves in a place where 2,00,000 people attended the wedding and aircrafts replaced the usual tractors and trucks for ferrying wedding guests. And who says a village cannot get 24-hour power. No load shedding during gadkari wedding! And no party-specificity with such rich rural weddings – so is the case, Sainath reminded us of the weddings of several others from all parties. India was so shining in these areas, that it was mostly blinding for many who didnt catch the irony. So much so that mass weddings with food were understandably the best social programme in Vidarbha for a long time.

The next 45 minutes was a series of anecdoetes from the 80s and 90s. The wisdom and experience of covering real India for decades was showing – he discussed the problem of “footloose migration” – those people for example from Orissa and Jharkhand who work for a few months in Hyderabad and later in Mumbai who do not get picked up by any census. We heard about that wonderful scheme that was pooh-poohed when launched – the midday meal scheme. The farmers rally or the strike at Maruthi’s Manesar plant for better working conditions that mainstream media took so late to cover. And of course, how many “luminaries” have rubbished all this tripe about farmers’ suicides and have proven it to us by legally deleting famine from their vocabulary through a parliamentary act! More followed on the food security bill.

All in all, it was a brilliant display of wisdom, erudition, spontaneity and a sense of conscience that Sainath demonstrates. He stands today as a conscience for several self-aggrandised and charismatic civil society who forget that it takes more than values and integrity to build a country. Describing himself as a member of the “un”civil society, Sainath repeated his thoughts on the Jan Lokpal Bill from that Berkeley lecture and gave tips on feeding our billionaires. 

And for those who would rather listen to Sainath himself and trust me the talk was one of his best  (the recording is not!) – see http://dl.dropbox.com/u/2047439/sainath/data-2011-9-16-19-05-15.3gp and http://dl.dropbox.com/u/2047439/sainath/data-2011-9-16-19-59-12.3gp (Thanks to Anush)

See also

• Indian media – politically free, prisoners of profit
• Three weddings and a funeral
• Reception after reception for Gadkari’s son
• Revenue foregone, but not forgiven
• Corporate socialism’s 2G orgy and all his other articles archived on India Together

A neglected statue and a neglected message

Some things are better assumed and neglected, than acknowledged and attended to. In public health research, these often find a passing mention in “Discussion” section where findings are explained, and worse still, may be as a “contextual” element. Prime among this is corruption. Corruption in health services is nothing new. Perhaps merely a sub-set of the general corruption prevalent in administration of public services, the corruption in health is much more than merely a “contextual” element to be taken into consideration in planning and implementing health programmes. Nor is it merely a feature that may explain some of the poor health outcomes that we often find. Corruption is directly, causally linked to poor health service delivery. We KNOW this and we SEE it. Yet, when I read several reports and documents at national and global levels, there is an obvious glossing over of this feature – as if this is some minor itch that governments will eventually get to.

In writing this comment to the Lancet, I had the privilege of partnering with somebody who has led a tirade against corruption in health services in my state, Karnataka in South India. As a chairman of a government appointed committee on health care for our state, he took a bold and courageous step in putting “corruption” as the main problem that the health services ail from. As I describe in the comment, this led to a long chain of events including the strengthening of the Lokayukta, an ombudsman institution that helps uncover corruption.

Yet, this is not enough! Over a decade of very active ombudsmen in Karnataka have not achieved much beyond making corruption a public issue. It continues to parasitise the reforms and innovations that we so fondly and techincally design for health systems strengthening. Of what use is a good HR policy if people accept money for transfers? Of what benefit is drug price control orders if there is collusion among officials and companies for mutual benefit at the cost of the system?

I really do not know what it is – lack of evidence? lack of resolve? In fact, I wonder sometimes, if corruption is a feature of the system or a bug?

NB: This appeared as a guest post on the International Health Policies Blog of the Institute of Tropical Medicine, Antwerp as a part of the Emerging Voices Initiative. Thanks to Kristof Decoster and David Hercot for the help and support.

Dr. Srinivas had started his career as a doctor trained from Karnataka’s oldest medical colleges, Mysore Medical College. He had joined the state health services early and had worked in remote primary health centres as a doctor and later in hospitals. He had risen up the long ladder stretching form a PHC medical officer to the level of a Project Director of Reproductive and Child Services for the State of Karnataka more recently. After retirement, his rich experience would not be wasted; the state continuing his services as a consultant to help implement the most important initiative these days, the NRHM. Among the lively discussions between the participants and him, was one important aspect of leadership – by example.

Dr. Srinivasa spoke of the fundamental nature of organisations; of adopting the values and principles of the leader. While most people are sincere in their work inherently, many others are fence-sitters, as he called them. They adopt the values of their leader. He also quoted from experience. It is critical for government services to produce such leaders, for in adopting these values of service and dedication, not only would they be transforming the way in which they work, but they would be transforming their entire institution.

Such is the case of the district hospital in Tumkur. The district hospital in Tumkur is an ancient one. It is one of the older large hospitals in the state of Karnataka, having been established a year after independence in 1948. By a strange quirk of fate, the then Maharaja of Mysore, Sri Jayachamarajendra Wodeyar, who was to inaugurate the hospital abruptly left the venue, for the day the hospital was inaugurated was the day that Mahatma Gandhi was assassinated. The inauguration stone that marked the occasion today lies within the walls outside the office of the District Surgeon. The hospital caters to over 2 million people in Tumkur district, and what a responsibility to manage a hospital of such a size given such a task….

Dr. Pratap Surya is the District Surgeon, the man who is at the helm of affairs at the hospital. He has indeed a mammoth task on his hands. Being the head of a large 250-bedded hospital that sees over 1000 people a day is no joke. A random sample of the patients reveals the enormous service that the hospital renders – one of the patients from Midagesi, a distant town in the taluka of Pavagada had come in search of the ENT surgeon for the chronic infection afflicting his adolescent son. He was a landless labourer from there, nowhere else to go for him; the bus charge from his place to Tumkur and back, and the wage loss resulting from a loss of one day’s work together added to quite a burden. There was another person from the town of Madhugiri, an old man who had come hoping to improve his vision by getting rid of the haze that had recently developed in his eye, a cataract. The hospital in Tumkur has an ophthalmologist and an ENT surgeon to cater to both of them. I ran into the gynaecologist, Dr. Diwakar in the corridor. He had just finished a caesarean surgery to save the life of a mother and the newborn. In this case, the newborn was positioned transversely in the mother’s uterus, thus not being able to be delivered normally; a classic indication for a caesarean section. If the mother had not reached the hospital in time from the distant village beyond Madhugiri town, the physiological process of childbirth could have been fatal for both the mother and the child. In her case, thankfully, the newly launched service of 108 had promptly brought her in time for the procedure. The woman being from a family that is below poverty line, like almost all of the patients that obtain service at the hospital had undergone the procedure completely free of cost.

The old man from Madhugiri will have his vision soon. The ophthalmologist scheduled his surgery for the upcoming batch. The ENT surgeon, who single-handedly manages the entire department will soon see the adolescent boy from Midigesi, in time for him and his father to catch the evening bus back home; he cant miss another day of daily wage. The taluka of Madhugiri could rest easy, avoiding its tryst with yet another maternal mortality, thanks to 108 and the gynaecologist at Tumkur. This was yet another routine day in the government hospital in Tumkur.

Yet, it is not automatically so. A lot of effort has gone into managing the hospital. It is but easy to target government hospitals for their poor quality of care and negligence. Easier still to say “privatise”. But, when one sees the segment of people who these hospitals cater to, we understand the importance of strengthening them; and it is not for lack of effort by the local staff that these ills plague the government system. People like the present District Surgeon, Dr. Pratap Surya are the foot soldiers of health care to the masses. Neglect and carelessness in the leader could easily have a cascading effect on the staff. But, Dr. Pratap Surya, by sending the right signals of integrity, service-mindedness and discipline – he leads by example.

Of course, there are problems. Why do poor people have to travel for such a long distance for an ENT consultation? Why wasnt the mother with a transverse lie diagnosed well in advance, so that she need not have come at the nick of time to the district hospital? Moreover, why aren’t such services available at the sub-district level itself? Why is the district hospital so overcrowded?

Thankfully, the launching of the NRHM holds promise. The priority accorded to maternal and child health and the resulting strengthening of referral units to prevent infant and maternal mortality, upgradation of neo-natal ICU’s in Tumkur district hospital, and of course the leadership by example provided by people like Dr. Pratap Surya, one can see encouraging signs of improvement. Let us hope that the efforts of several people within the system like the district surgeon or Dr. Srinivas and many others among the Tumkur district health team will result in better quality service to the poor.

I have a dream….

If Martin Luther King were born in the forests of BR Hills in Southern Karnataka during the nineties, apart from perhaps running into Veerappan, he could’nt have expected more adventure. Nonetheless, I am sure he would still have had a dream.

His dream would have to do much more with owning a television and watching an action film. It may have been about having a bulb at home and a tap with water. It may have been about seeing the insides of a car or wearing colourful clothes. These are some dreams that a ML King look-alike, Ketha has in BR Hills.

Ketha from Gombegallu

Ketha is a Soliga tribal boy far removed from the realities that some of us take for granted. He does not have a facebook profile and the only tweets he hears are that of a a bird which shares his name, the Kethanakki, named after a tribal god’s coming that this bird announces promptly. He lives in a small hamlet within a wildlife sanctuary.

His life is a part of several debates in which he has no voice. There is for example the school of thought on development that wonders why indigenous tribal people are being ‘developed’. What about erosion of their culture? Another argues passionately that the fruits of development (Facebook and twitter included!) cannot be denied to them. The State refers to him as marginalised and has scheduled him.He is one of the 400-odd tribes in India constituting 8 per cent of our population.

Another group of people strongly believe that he and his kind living in protected areas are in fact the obstacle to the conservation of our forests. Wherever, man and wildlife have tried co-existance, some say has ended in a diasaster. Inviolate areas for wildlife are touted as a prerequisite for any conservation strategy. Others weave a more utopian reality for Ketha, suggesting that conservation of wildlife and human livelihoods can go together. Others nuance it further saying that this has definitely happened in some areas. Ketha, of course is blissfully unaware of such realities.

Where would he read these debates? In the textbooks….

Hardly….In the textbooks, Ketha finds references to events, he cannot understand even….such as September 9/11 terror attacks on the US. While, this chapter in the 9th Standard English textbook of Karnataka State Board makes a good effort at trying to convey to Ketha what a watershed these attacks were for global politics, it perhaps misses the boat on connecting with him on issues closer home such as tigers, tribal people or traditional knowledge.

What about the internet? Hardly. Ketha has no access to the internet. Having a local NGO run a school itself is such a privilege for him, when compared to his other tribal brothers in other areas.Perhaps, on the internet, Ketha could have participated in these debates that adorn journals and blogs.

Ketha and Pareto come to my mind as I read the recent guarantee of broadband internet access to every Finn as a fundemental right. I still remember joking about how I am waiting for the day when the Indian State will guarantee 2 Mbps per citizen with unlimited download as a fundemental right. Less than a year from my joke, a country that Ketha has never perhaps heard of, has guaranteed it. Recently, when Michael Moore made that wonderful ‘reality show’ called Sicko, he apparently removed scenes shot about the Norwegian health care system, because, nobody would believe it!

Anyways, my point is that there is today within Ketha’s lifetime, a country where broadband internet access has been granted as a fundemental right, while in Ketha’s country, we are still wondering how to give him and his kind a good primary education.