Thursday, August 30, 2012

Machine Mindedness

Machine-minded
He disposes and discharges
As if they are tools in his hands
Pity
Those machine-like slaves
But also him
Who lost his soul.





(frustrated at the way I was treated by superiors the last few days)

Monday, August 27, 2012

The other Nagas in our midst

For Eastern Mirror Column 'Health et al.'

Many Nagas do not know that there is another Nagaland which exists right under our nose: The bottom half. They are simply numbers in our census. We do not know their names, we do not discuss them, and we do not hear their voices or ever meet them face to face. If you are reading this, perhaps you are one from the upper half who is ignorant of this sad reality. Once in a while, some people from the upper half unassumingly travel to the land of the lower half and to their horror, see for the first time that there is another Nagaland which is so different from the Nagaland we believed to be living in.

Many Nagas today, who are born, brought up, or lived long in towns and cities are so ignorant of our own fellow Nagas who live in the villages. We think we are all basically from villages and we are more or less the same. Some of us naively believe that Nagas are equally progressing; that we all wear similar clothes and drive similar cars. We think we are all getting along fine. ‘Aren’t peons and chowkidars driving cars and using mobile phones?’ we say. Town kids are also blind to their own native places, can hardly speak their mother tongue, and much less, understand the living condition of own kith and kin. VIPs and Big Shots who go on flying visits to such places on special occasions hardly get to see the day-to-day drills of a village life. They meet the VIPs of the village, eat from the officers’ mess, and leave before sunset. There is a story of a king who disguised himself in ordinary clothes and roamed at night to see how his people really are. If our big shots were to emulate that king today, ‘shed off’ their escorts and status and live as the villagers do; in a few days, they will discover to their bewilderment that in fact there is a totally different world, a sort of a parallel universe in our midst.

I’m from the upper half. I was raised in a town and have never lived in the village for long after school. And I don’t mean at all that I am a champion of the lower half. Far from it, I do not understand half a fraction of what the half is like. But like a peek through a window, I, like some of the lucky few from the upper half, have seen this complexity of our Naga existence. I do not want to name any name or place, for we are all equally made in God’s image and share the same world he created. I guess it is a privilege and a burden that doctors get to see people when they are at their worst. As I hold the hands of these people, their palms bear the marks of the hard lives they live. Many of the children have bloated abdomen, not because of overeating but malnutrition and worm infestation. They die from diseases which could have been treated by a salt and sugar solution. I’ve been to villages where backache and knee pains are endemic. It is a sinking feeling to imaging telling a farmer to change her occupation because that’s not good for her backache. During my brief spell of stay, I tried to understand the social conditions related to their illnesses. One guy came to the health centre with burning pain abdomen. After coming to know that he survives on corn as substitute for rice (which is too costly for him), giving dietary advice landed me in an uncomfortable and unfamiliar position. I faced situations where medical text books offer no help. Many people in the villages live with pain unattended to. Imagine staying for a day with pain. And imagine if that pain is for all times and is a ‘way of life’. Especially old folks are not taken to hospitals just because they are old and they have consigned to their fate of living with pain.

The economically poor villagers suffer not only from lack of material wealth but also suffer discriminations and dehumanizing treatments. Some urban folks go to the villages on relief missions, click pictures with dirty children, give away aid, and come back feeling good about themselves. Sometimes, giving of charity can be dehumanizing to the receiver. Poverty is not a cute thing when met with face to face. It was some years back, when I was watching on television a celebrity who was raising funds for aid in Africa. She travelled to Africa and visited the homes of the destitute poor. She wept uncontrollably on seeing the poor people. Her cry was raw and unrehearsed. It was a cry of someone who came face to face with poverty. She was shell-shocked that such poverty exists in the world. The poor are not objects of pity but fellow human beings who need a helping hand. They are people who are wronged more than often, and what they need is not alms but justice. It is common the world over that the rich exploit the poor, snatch their means of subsistence and treat them as sub-humans. Our society is not spared of this pattern. The funds meant for the poor and underprivileged are snatched to build private mansions and fund family shopping vacations. Those who grow rich overnight make no bones about it and feel no needle prick in the conscience. And we join in the celebration of their instant prosperity. A thanksgiving prayer is in place. This unaffected we have become because we do not feel the effects of our actions. Those who suffer for our actions are invisible and voiceless.

Take a trip. Make no big plans. Accept no grand reception. And go to the invisible, voiceless Nagas in our midst with this attitude:
The villagers may be illiterate,
but they are not ignorant or stupid.
They may not be modernized,
but they are not uncivilized.
When we go to the villages,
learning has to be mutual.
For inclusive growth and development of our Naga society, the first thing to do is to recognize and understand the reality of that great divide in our own land.

Thursday, August 23, 2012

Silence

(Tsazu, Kikruma)
Silence doesn't mean it is over
But when all is said and done
The only option left is Silence.

Tuesday, August 21, 2012

The Juice if flowing

 It is 1:00 am 
and neurons are firing.
The juice is flowing
and my pen is harvesting.
Blessed be his name.

Saturday, August 18, 2012

Cultivating sanitary practices as a habit of the mind

For Monday Column in Eastern Mirror.
At Dimapur, Photo: Caisii Mao (demotix.com)
‘India is a country where Atomic Age and near Stone Age people co-exist’. PK Jha

‘You can take a horse to the river, but you can’t make it drink’.

Dustbins can be provided in public places by community decision, but how do we make individuals throw waste into those bins and not elsewhere? That question is literally worth lakhs of rupees even for a small State like Nagaland. World Bank estimates that India loses Rs. 24,000 crores annually due to poor hygiene and lack of toilets. Rs. 17,000 crores are spent on the cost of treatment due to illness from insanitary conditions and 4.5 lakh people die from such diseases every year. It is estimated that Rs. 1,000 crores are lost from tourism revenues because travelers find India to be too dirty. The infamous ‘Delhi Belly’ is the term referred to illnesses acquired from eating Indian food!

Last month, I saw two empty Mazaa (drinks) packets flew out of a staff bus window into the main street at the heart of the Capital of Nagaland. I saw that as a challenge; a challenge to our beloved State. I asked myself, ‘How can we make those employees in that bus and others like them to throw waste into dustbins and not elsewhere?’ The future of our sanitary condition lies in how far we can do in response to that question.

In health education, a relatively new concept is called Behavior Change Communication (BCC). I’m not from Communications background and I don’t know the details of what it means; but I find the concept of behavior change fascinating. I know that one of the most difficult things to change in me is my behavior. Doctors need not be taught that tobacco is injurious to health, but many doctors consume tobacco. Tobacco is an addictive substance; but to try to change one’s behavior is not very different from that. You and I know that to change one’s behavior is tough even if we are convinced that the behavior isn’t the right thing.  To be convinced beyond doubt that sanitary lifestyle is necessary for good health does not automatically result in behavior change. A sense of cleanliness does not necessarily come with a university degree or rise in socio-economic status. I’ve been with research scholars in JNU, Delhi who lack personal hygiene and no amount of university education can make them throw used paper cups into dustbins five feet away. Also we see people throwing waste out of fancy cars into paved streets.

Is this something peculiar with us Indians? Why are we so dirty? Aren’t Indian ancestors the pioneers in building sanitary baths, underground sewage system, water supply and sanitary devices and the world’s earliest flush toilets  from the Indus Valley Civilization, which were much before the Sanitary Reforms in England? Susan E. Chaplin explains why the successful sanitary reforms in the latter half of the 19th Century in England was not felt in India. One reason she says is,
‘In India, there is little middle class pressure for sanitary reform, in part because of the ability of the middle classes to monopolize what basic urban services the state provides, in part because modern medicine and civil engineering have lowered the health risks that they might face from the sanitation-related diseases that lower income groups suffer’.
Well, even today, there is a real chance that some people would drive through a dirty neighborhood and not smell the stench by simply rolling up their car windows, and do nothing about it. Those who can afford modern sanitary technology can ‘cordon off’ their own compounds and it is the poor who suffer the brunt of the insanitary conditions. People whose voices matter do not speak out and those who suffer the most have no voice. Another factor, I suppose, is Caste; where some people are ‘clean’ and some are ‘unclean’ by birth. For the upper castes, it is simply not their job to clean up stuffs. In this time and age, it is disgusting that scavengers still exist who manually handle other peoples’ shit!!

Can change of behavior be enforced? Only temporarily. Take away the force and the behavior bounces back to its original shape. But certain enforcement is necessary to develop a sense of cleanliness. An example in point is the Delhi Metro. Once inside the metro station, the same people who are polluting the street corners suddenly stops to do so. Every few minutes, there are announcements to make the passengers aware that it is a punishable offence to pollute the trains and stations. People comply, not because all of them feel it should be so, but for fear of punishment. So, even though for a short while, people maintain cleanliness. They are made to. In the advanced countries where people enjoy clean living conditions, there are strict laws and tight enforcement of such laws.

Therefore, what needs to be done to bring about sanitary living conditions have to be multipronged actions at various levels. First, there is a need to educate the people through BCC. Not through a onetime message, but repeated hammering until sanitary practices becomes the ‘natural’ thing to do; that it becomes a habit of the mind. Various tools of communication can be used or devised; tools with solid evidences and arguments to persuade people. It should be vigorously taught right from primary school level. Next, there is a need for legal and punitive measures to prevent polluting the environment. Since smoking in public places became punishable, the incidence has reduced. Some people still break the law, but for fear of sanction or even embarrassment, we don’t see people smoking in public places as much as before. Likewise, make littering of public places punishable by law. It may be difficult to enforce certain laws which may seem trivial, like urinating in street corners, but such laws can deter people by instilling in the minds of people that such deeds are illegal by the law of the land. Lastly, the society must create environments which are conducive for sanitary practices. In telling people not to litter, public dustbins and waste disposal mechanisms must be put in place. Construction of public toilets is necessary along with prohibition orders put up on street corners. Water supply, drainage and sewage system, community solid waste disposal mechanisms, etc are beyond the capacity of individuals, and the local governing bodies like the municipal, village council, etc. need to ensure that these are put in place. So, BCC activities have to be targeted, not only at the public, but to those policy makers, planners, municipal and public leaders whose one decision can affect thousands of lives.

What we need is a sanitary reform movement to sweep through our land engaging all the levels from the individual behavior to policy decisions. The efforts should not be fragmentary; they should be concerted and simultaneous. A remarkable change that came out of the sanitary reforms in 19th Century Britain which was quoted by Chaplin is, “The success of the sanitary movement… brought about a ‘disciplining of human behavior…’” That should be the ultimate goal, when sanitary practices become ingrained in our genes informing our behavior which guides our actions.

Online shopping

OK, I received my salary after 4 looong months. So, I ordered two books online:

1. The Politics of Sanitation in India: Susan E. Chaplin
























2. How much should a person consume?: Ramachandra Guha

























They must be on the way. :-)))))

Monday, August 13, 2012

A dream for 11 solid district hospitals in Nagaland



It is a wishful dream. Maybe someone else has it too. And I hope I don’t spoil it by sharing it now, because I feel more time should be spent on research before putting it out in public. It is a work in progress.

A patient from Pungro in Kiphire district has to travel about 290 kms to the State Capital for an Ultrasound and most of the other routine diagnostic tests. Also, apart from the doctor’s prescription pen, treatment facilities are very limited. Patients from Mimi or Thanamir villages have to walk for half a day or hire a vehicle to reach Pungro. For people in this area, the time wasted, the labor days lost, the worry, the difficulties in finding a place to stay in the Capital, etc add up to the travel and stay expenses, and medical bills. So, it is a hard decision to embark on such journey to seek for medical care. Such patients tend to reach Kohima in critical condition after complications have set in. We blame such village folks for their ignorance and scold them for coming late. But we know that we recover from certain illnesses without medicines, and the difficult conditions of such people force them to bargain and risk too much. For it is not rocket science to know that if one gets sick, one has to visit the doctor.

This dream that I have is that one day (hopefully sooner than later), patients from such far flung villages have to travel, at the most, to their respective district headquarters. In their district hospitals, comprehensive medical care is made available - routine diagnostic, medical and surgical packages – so that only in extraordinary circumstances, cases have to be sent out for referral. So, a patient from Pungro has to travel only about 40 kms and save 250 kms. She would not only receive early medical care and save the additional journey expenses but would also be cared for in familiar surroundings of her own district. She would feel more secure as it is nearer home and the relatives would also get more flexibility and more helping hands in caring for her.

This isn’t asking for too much as it is simply asking to put in place what a district hospital should be like. Some district hospitals are doing better than others, but in majority of them there is a need for major fixing. The blame game is a vicious circle where there is no end. You trace the reasons for the sorry state of our hospitals and you end up having your ears full but no clear vision for a way ahead. I in no way would like to project my own department in a bad light and you’ll see that this article is far from picking at its faults. The factors responsible for the present state of our district hospitals are multi-factorial anyway. No single entity can be solely blamed.

The health service delivery system in India is like a pot of ‘galho’. The ingredients are so mixed up so that it is very difficult to make out what went in the pot. Each government would add some new ingredients during their tenure, stir the pot a bit, and go away. The next would come and do the same. There are over a dozen vertical national health programs which are more or less, independent of each other. The programs have their own elaborate systems of functioning with separate employees, reporting through separate formats, aiming to achieve specific targets, and funded by different agencies. But the sum of these vertical programs and the general health services form a very confused health care delivery system. The programs are all so messed up that one doesn’t know what the other is doing. We, who are involved in a specific program, are so busy in our own worlds that if we are in-charge of the liver, we don’t know if the kidneys are suffering, much less that we are all body parts of a whole person. No matter how useful the specific disease programs are, the general health services is the most important and the most neglected in our health care system. The national programs were meant to support and improve the general health services, but I think they have taken us away from it. That I think is an important cause for the state of our district hospitals. The NRHM has been trying to integrate these different health programs to form a coherent health care delivery system, but that too is still a work in progress. So, we are caught in this juncture which is not of our making but is a confusion that is felt in the whole country.

Some States which have sufficient local resources and clear vision are able to stir through this state of affairs well. As health is a State subject, we also need to carefully plan for the health care delivery of our State, over and above what Delhi tells us to do. What needs to be clearly understood is that the various national health programs are not the health care delivery system per se, but only supporting wings. They all require a well functioning general health services, consisting of the subcentres, primary health centres, community health centres, and the district hospitals. And above all, we need well functioning district hospitals. And the day-to-day functioning of the district hospitals is beyond the purview of the national health programs; it is in the hands of the State government. The State, with its limited resources has constraints in keeping our hospitals in healthy shape. And as stated earlier, the national programs have diverted our attentions away from this primary task.

The first and the most important thing to do, is for the State to allocate its budget more in health sector. There is no getting around this if we want to see improvement in the health services of our State. Next, with proper planning and strong policy decisions, arrangements can be made where the limited resources, like technical manpower (e.g. doctors) can be relocated from the lower levels to the respective district hospitals. With the hospitals functioning with multiple specialties, they can become learning grounds for medical officers, and patients receive comprehensive quality medical care under one roof. The doctors can visit the primary health centres on specific days of the week and perform their duties in rosters and no one is overburdened. A medical officer may be assigned to fill the multiple reporting formats and other paper works, and in turn, he may be relieved of emergency duties. Some may not agree to this arrangement but the idea is that whatever the arrangement may be; overall, there is a healthy combination of work, leisure, study, and family life for the employees. Such arrangements are of little relevance for a newspaper article as this, but it is simply to show how we can plan to work more effectively with the resources we have. With clear vision and elaborate planning, we can do a good job with what we have. Lastly, and the thrust of the write-up is this: The other departments, civil society groups, faith based organizations, and individuals need to play a much more supportive and pro-active role in building up our district hospitals. Criticisms and voicing of grievances can be constructive. But there is a need to go beyond that to actively contribute towards our hospitals. The respective District Planning and Development Board need to have the district hospital in their agenda for development activities. The Power Department can help by supplying special lines to the hospitals because almost all of the modern medical equipments run on electricity. The PHE department can ensure that there is sufficient water supply, because it is useless to talk of sanitation without sufficient water supply. The local MLAs can donate an Ultra Sound machine this year, a generator next year, and so on. The tribal hohos of the respective districts can mobilize local support to construct certain rooms with locally available materials. The church youth can offer to clean up the hospital surroundings every month or quarterly. Individuals can contribute decorative items to make the hospital wards more homely. Some families, whose love ones recovered from the hospital, can donate a television set or a table tennis table for the recreation of doctors. There are umpteen things that groups or individuals can do for the hospitals. Ask the Medical Superintendent, ‘what can we do for the hospital? What is the pressing need now?’ Irrespective of who is to blame for the lack of this equipment or that medicine, something can always be done if we are concerned. It is a commendable job that The Naga Blog, an online group, volunteered to renovate a part of the Dimapur district hospital. The local MLAs, tribal hohos, students’ bodies, church councils, and individuals can take cues from that.

Wednesday, August 8, 2012

Tea drinkers more likely to go to heaven

Another half baked article for weekly column :)


Health Et Al.There was a study conducted by the Faith Research Institute, Notown which showed that tea drinkers are more likely to go to heaven. Tea drinkers have a higher percentage of having ‘Born Again’ experience than the control group which does not drink tea.
It is probably because religious people have a higher tendency to meet over a cup of tea and talk, where the gospel is preached and more people experience being ‘Born Again’.

The above research is a fanciful study done with questionable methodology from a non-existent research institute in an imaginary place called Notown. But I wouldn’t be surprised if there is a research done on such a topic showing similar findings. One must be cautious in interpreting the research reports that we see in newspapers and journals almost every day. There is already a study which found that sitting is injurious to health. In health, strictly speaking, every human activity is injurious to health. Because of ageing, even Time can be said to be injurious to health. Jogging, although proven to be beneficial, can also be injurious to health. There are bacteria and viruses lurking in the grasses which may pounce on morning joggers and infect them.

In the above hypothetical study, one may have to ask certain parameters which may not be clearly stated: (a) Say, 80% of tea drinkers reported having experienced ‘Born Again’ compared to 73% among those who don’t drink tea. But if the sample size is too small, the responses of a few will significantly affect the result. Likewise, inferences coughed out from opinion polls in the newspapers can be tricky when we don’t know if the number of participants taking part in such polls is substantial. (b) One also may question the underlying parameter of using ‘Born Again’ experience as a ‘ticket’ to heaven. Hidden agendas while framing the research objectives and preconceived ideas while preparing the questionnaire can be masked in research language. If we want a particular result and do a research to prove it, the interpretation of research findings can be also tilted towards that end. To sell a product, companies may simply conduct certain bogus research to proof the quality/superiority of their product. One may also draw inferences out of some finding which the research is not intending to study. What if the above research is interpreted as, ‘Drinking tea causes people to go to heaven’. Then, people start to drink tea in order to go to heaven. Causality and Association are not the same. Association of two factors doesn’t mean one is causing the other. There was instance when research in Homosexuality was presented in the media, something like, ‘we have finally found the gay gene which causes homosexual behavior,’ while it was only association of factors. (c) For the sake of the next point, let's say that drinking tea causes people to go to heaven. Now, the question is, 'What is the use of the research?' Will the result educate people to change behavior (start to drink tea) and shape public policies (investment in tea production) or increase human knowledge (of the properties of Tea or the concept of Heaven?) If not, what is the utility of a research linking tea drinking to going to heaven?
Some instances where research is not all black or white and can have important repercussions are given below:


  • Fellow doctors need to be cautious of many so-called research findings that pharmaceutical companies provide in the OPDs to back up their products. There are reportedly so many bogus drugs and questionable claims of drug properties. They may refer to research studies published in some ‘Journal’ but that doesn’t necessarily make them authentic. This is when Peer Review and reputation are very important. The Lancet, for example, is a reputed journal and will not publish just any study without fulfilling certain scientific criteria. The same goes for other market products where certification/authorization from reputed agencies (ISO, BIS, etc) is an important factor to look into.
  • Is using mobile phone injurious to health? The answer is still not clear. Some researchers say it is harmful while others say it is not or the risk is minimal. To Telecom companies, I guess that is literally a billion dollar question. If a telecom company does a study and says it is not harmful while a study by some other party found it to be harmful, that wouldn’t be surprising. Such things do happen. Some of the health programs and disease control initiatives are politically charged territories where vested interests clash with genuine concerns for reduction of human suffering. Research is extremely important to decide which side the course of Health programs will take.
  • In the guise of medical treatment, research institutes can make guinea pigs of us. India has overtaken China as the number one destination for drug trials. Even before proper animal trials, there are reports of studies done where new drugs are tried on human beings without explaining the purpose and the risks involved. This does not mean that we should be closed to researches altogether. In the past, I was told that we refused to give blood samples for fear that it may be used against us. So, when we read the National Family Health Survey, we find that some health statistics are missing for Nagaland. If the researchers had sinister intentions, there are thousands of us staying outside the State who are visiting hospitals and giving blood for various tests. Nevertheless, we need to be careful that we are not taken for a ride. For a few incentives, we should not sell ourselves as laboratory materials.
  • You see a TV commercial of a toothpaste which promises extra and long lasting shine, and the evidence is certified by a dentist in white apron. A sunscreen lotion prepared by using some German technology gives extra UV protection. 51% of the people who used a health tonic (for Rs. 999 only) felt younger in 7 days. And we buy such stories without a second thought. We see a product with a 70% discount and buy it not knowing that the original price was hiked. We see a good offer but forget to notice the asterisk indicating ‘Conditions Apply’. Advertisements backed up by cooked-up researches such as the Notown study are on the rise. Think again. Nagas can be gullible and be easily taken for a ride. For instance, many people from other parts of the country have disappeared with our money after false promises. So, even in our everyday life, we need to be on our guards and keep on doing small researches of our own.