INDIA'S HEALTH - SOME SHOTS ON FRONT FOOT, SOME ON BACKFOOT

CURRENT SCENARIO

India has crossed 15 lakh persons detected suffering from COVID-19 the dreaded disease which spread across the world since the New Year Eve. About 35 thousand died and rest recovered as per data available as on today. (Ref india covid 19 tracker). Fact that the authenticity of this tracking data remains doubtful and that the sample serosurvey conducted by ICMR in April 2020 is more reliable, at its national average rate

of population infected 0.73%, one can infer that about 10 million should have been infected, on end of April 2020! Applying the doubling rate in India, till today about 150-160 million are already infected - 16 times more than in April! If one assumes that the death models are accurate and estimated as per Infection Fatality Rate suggested by Lancet, then around 5,6 million are infected. Therefore, it is clear that between 5.6 million to 160 million of us are infected with Covid 19. This means 0.04% to 12% of our population is having or had Covid 19 during past 5 - 6 months.

Do you remember the past pandemics our ancestors had faced - Bubonic Plague which took away 12 millions over 44 years while the same number of people succumbed to Spanish Flu in 3 months in 1918? In both the epidemics, the Government and our own volunteers, missionaries jumped in to provide services, so, did Gandhiji! the Government stepped in  with masks and isolation. No medicines and vaccines were not available. The undetectable, rapidly spreading virus  took tolls in a very short period of Spanish flu. When the enemy is invisible, an instinct takes over one's rational thinking, it seems - we start blaming 'the other' - the government, the neighbour, the religion or even a voo doo. 102 years later we are facing similar challenges: during the current pandemic it is learnt that it also generates denials, rumours and mischiefs.

WHAT CHANGES OCCURRED IN OUR HEALTH STATUS POST INDEPENDENT

India faced poverty, illiteracy, lack of information, superstitions, absence of health care services - public or private, people dying at home due to cholera, plague and flu, at the time of Independence. We have gone far ahead since then.  Let us take a stock of  the current health scenario today. .Birth rate was around 40 (no. of live births/1000 population) in 1947, it is 20 today. Infant mortality rate (no. of children die before completing 1 year/1000 live birth) was 200, reduced to 33, now!  Maternal Mortality Ratio per 10000 live births has reduced from 2000 during 1950-57 to 113 in 2016-18.  Life expectancy then was 32 years, it is 69 today. In 1947, 27 out of every 1000 people died every year, today 7.

DEMOGRAPHIC AND EPIDEMIOLOGICAL TRANSITION IN INDIA

In the past 70 years there are several changes in our nation. some Good, some Bad and some Ugly.

Age Structure of Indian Population:

Births equal Deaths-
Before independence, we were in Stage 1, wherein Birth rate and death rates were almost equal, hence Population was stable and age distribution was different than today. Today, we are in Stage 3, there is an increase in 25-64 age group and decrease in 0-14 age group.

Rural population shifts to Urban-
83% of Indian population rural population was living in villages and 17% in towns and cities in 1951. ( https://censusindia.gov.in/DigitalLibrary/data/Census_1951/Publication/India/23685-1951-REP.pdf) As of today, 68% are living in rural and 32% in urban areas.

Communicable Diseases as killers level off with Non communicable ones-
Similarly, there are transformation in causes of deaths: more people die due to non-communicable diseases like Cardiovascular diseases, Diabetes, Strokes, Diabetes and Cancer or Suicides, Substance Abuse or accidents are emerging. There is reduction in deaths, increase in age of deaths, causes have changed. This in technical term is an Epidemiological Transition across the country, more so in states like Goa, NCT, Kerala, Karnataka, Andhra Pradesh, Maharashtra and Gujarat. Instead of child deaths and severe communicable disease, the non communicable illnesses like mental illnesses, backaches and joint pains, diabetes, heart diseases or obesity, deafness like chronic illnesses are the burden on the longer living human beings.

In a sense, living longer is a boon; but living with chronic illnesses is a bane.

Why this epidemiological transition
All these changes have occurred thanks to government policies, health programmes, new knowledge and new technologies, no doubt. Malaria, Leprosy, TB elimination occurred due to effective national health programme co-ordinating upto each village and town. Universal immunization indeed eradicated small pox polio with a robust implementation and surveillance programme. We hardly have here diphtheria, whooping cough or tetanus, nowadays. Better safe potable drinking water and sanitation has also made illnesses like cholera, diarrhea almost none or declined. These programmes are driven from top to bottom, from MoHFW, GoI to the Primary Health Centre in the villages. All this assures us that though the 1918 Flu epidemic killed 12 million in India, 2020 Coronavirus would not kill so many. (Even though the current death figures due to Covid 19 are challenged, most experts consider it that it may not be exceeding 1 lakh!) All this achievement and assurance is certainly due to strides in science, technologies, increased awareness and community involvement as well as government's policies, programmes and mechanisms to implementing them.

One must be cautious of the 'victory' of declining communicable diseases, as Coronavirus has taught us! This is not the end of them. It is natural that out of millions of viruses 'living' here or other germs in symbiosis may mutate into new viruses, germs (pathogens) and use the living being to survive, if other source is not abundantly available in our environment. This ecosystem has sustained our living planet for the past billions of years. And it will continue to do so till the cosmological changes end the planet itself. Till then, diseases like AIDS, Covid 19 may emerge and infect the humankind.

THREE STEPS FORWARD; TWO STEPS BACKWARD

We have acquired leaps of knowledge, skills and technologies, management systems to understand human bodies and health systems therein; ecosystem which affects the human body - environments incl. other animals, human made pollution and changes in its effects, natural disasters and its amelioration; diagnose, treat or prevent illnesses of communicable and non communicable or genetic types using devices and drug; removal of organs creating the problem and replacing with other healthy living or human made organs since the last 40 years, with all the banes of organ transplant scams. There are backward steps in human made pollution, in overuse of medicines, deterioration of human values while treating the human being.

 One step Forward: Health knowledge and Care providers

In 1947, as per the Bhore Committee, India had about 56,000 doctors mostly practicing and 8050 trained nurses, 725 PHCs, 29 Medical colleges  in 1950 have now grown to about 8 lakh doctors, 11 lakh nurses, 22000 PHCs and now more than 537 medical colleges and and continue to grow. Here, the distribution has changed, while in 1947, there were hardly any medical practitioners in rural areas, they are now available though the growth in urban area is faster. 

This is a national picture; the variance in each state and in rural, urban and tribal areas the distribution is very different and gives the clear situation. A McKinsey Study in 2001 had shown that while urban location have 34 doctors  villages had 6 doctors only per 10,000 population,! While, the health infrastructure is growing but its distribution and reach to the population is not maintaining the required pace. Covid 19 has shown us the deficit of all the four indicators to match the need, in any state and city. 

 Second Step Forward: Diagnostics and Medicines

 Medicines - Available, Affordable and Accessible

India is one of the largest pharmaceuticals producing company in the world, more than 25000 companies including multinational ones will produce about 100 billion USD worth medicines in 2020. 80% of Anti retrovirus medicines are produced in India and so is generic medicines.

 Cipla, East India Company like pharma companies established in 1935-36 continuously produce medicines at affordable drugs. There are many companies established by the government like Hindustan Antibiotics, Bengal Chemicals & Pharmaceuticals Ltd., Haffkine Bio-pharmaceutical Corporation Ltd. etc. which is producing antibiotics, painkillers, vaccines, antivenines etc. (See https://thingsinindia.in/pharmaceutical-companies/#:~:text=Cipla%20can%20be%20called%20as%20a%20pioneer%20of,a%20presence%20in%20many%20countries%20around%20the%20world.)

 

We have a robust regulatory authority which establishes the drug marketing and pricing limits, hence not just for us but for other countries quality and affordable medicines are available thanks to this sector. 

Even so, its availability in public health sector is a challenge. According to a recent study done by Brookings Institution India published in March 2020.(https://www.brookings.edu/wp-content/uploads/2020/03/Medicines-in-India_for-web-1.pdf ) medicine cost form 43% of Out-Of-Pocket-Expenditure in India, which in itself is 65% for India versus world average of around 20% in 2016 of total cost of health care. Rest portion of OOPE consists of private health care, diagnostics, transport etc. 

The other pathies - AYUSH medicines were being produced by authentic Ayurvedic medicine producers - the vaidyas, following the their pathy directed by them. Particularly, the Ayurvedic medicines are being produced by these companies but its uptake is less. Partially, because of committed AYUSH practitioners. Mostly graduates join allopathy and conduct cross-practicing. This has repercussion on quality of services also leading to neglect of their own education, their nighantu, ras-shastra, nadi parikshan, Repertoire, Materia Medica etc. 

 Diagnostics - Whether thou so necessary?

According to Dr Ravi Gaur in his article Growing diagnostics market in India (https://www.biospectrumindia.com/views/70/14454/growing-diagnostics-market-in-india.html) in Biospectrum, diagnotics is growing annually in India mainly in Tier 2 and 3 cities, at 20% in General Pathology and 30% and specialized pathology like biopsy, genetics, oncology, genomic sequency,  radiology etc. at 30-35%! Tier 1 cities are almost saturated. In rural areas even in the public health sector there is little growth in routine lab for biochemistry, microscopy etc. 

However, there are some big challenges in this sector. One is its management: since this sector is rapidly getting digitized from cell counters to digital radiology. Management of a path lab has 3 components pre-analytical (sample collection, delivery to the lab and bar coding), analytical (pathological analysis which is automated long time back) and post analytical (is concentrating in errors occurring in the post-analytical (i.e. delivery to the doctors, its reporting, its interpretation and its application - stand alone or holistically, with other reports - to the patient). Management is focusing on errors in pre-, and post-analytical sections now. The second challenge is that it is almost like a market - anyone can open it, no accreditation, qualification of the person running it, pricing and its quality.  There is no regulation either technical nor professional. Clinical Establishment Act needs to be nationally applied to provide quality and affordable service.

Professionally, the challenge is a clinical practice becoming dependant not on clinical manifestation of a disease in a patient but on the path lab reports. Thus, all the clinical learning about the human body and mind, the gaze has shifted to what machines say in order to perform a doctors' duty. What our teacher used to tell us in 1970, while auscultating a young patient having heart disease with our ordinary stethoscope in place of his Chugg's, " What matters is between your ears, and not in your ears!" is becoming

Third Step Forward: Universal Health Coverage  and Health Financing

A High Level Expert Group (HLEG) on Universal Health Coverage (UHC) was constituted by the Planning Commission of India in October 2010. The HLEG  had the mandate of preparing a framework for accessible and affordable health care to all the citizens of India - for the rich and the poor, for all castes, religion, gender, age groups. urban or rural residents.  Main aim of this initiative was to ensure financial protection, it also covered healthcare infrastructure, skilled health workforce and access to affordable drugs and technologies to ensure the entitled level and quality of care to be given to every citizen. Further, the HLEG recommended that delivering various health care services/programmes require an efficient management system and  empowerment of the communities. It also suggested that about 2.5% of GDP should be allocated for health care, state should spend 8% of their total budget, 70% of all expenditure under the UHC package should be spent for primary care, and rest on secondary and tertiary care. This includes".. general health information and promotion, curative services at the primary level, screening for risk factors at the population level and cost effective treatment, targeted towards specific risk factors," (http://uhc-india.org/reports/executive_summary.pdf) 

National Health Policy 2017 adopted almost all the components and converted into Swachchh Bharat for Sanitation, Ayushman Bharat - Health and Well Being programme as extending Primary care to the villages and PM-JAY a health insurance package for the poor and marginal population for specific health procedures. 

This is a laudable approach which assures most of the Indian citizen. But we are far from reaching anyway near the laudable goals.  Target 3.8 of SDG 3 Health and Well Being considers - 100% population coverage, 100% services coverage, and financial risk protection upto 10% of their Household Expenditure as indicators of monitoring the UHC. India's index of population coverage for essential health services in 2017 was at 56 and was worse than countries like Mongolia, South Africa, Sri Lanka, Thailand, Vietnam. About 17% of the population incurred catastrophic health expenditures behind countries like Bangladesh, Rwanda, Sri Lanka, Vietnam! 4.2% fell back into poverty due to spending on healthcare, again worse than the same countries. India's indicators for financial risk protection were not upto the global averages and the averages for Low and Middle-Income Countries (LMICs)  (https://openknowledge.worldbank.org/bitstream/handle/10986/29042/122029-WP-REVISED-PUBLIC.pdf?sequence=1&isAllowed=y). The variance in states, districts and locations where vulnerable groups are surviving would be high inequalities by socioeconomic status and across than what.national averages show. ( https://apps.who.int/iris/bitstream/handle/10665/259817/9789241513555-eng.pdf;jsessionid=452A5CD87F4B75E22321D432765DC3C3?sequence=1

One Step Backward: 1.Tribal women, youth, children and elderly requires special attention:

 India has 645 distinct tribes including 75 primitive tribes in the country having distinct language, culture, social practices and certain genetic traits causing certain illnesses like sickle cell anemia, alpha- and beta-thalassemia, glucose-6-phosphate dehydrogenase (G6PD) deficiency etc. Other health indicators like malnutrition, life expectancy, maternal health etc. requires a different approaches due to their socio-economic, residency etc. The total population of Scheduled Tribes is 10.43 crore as per the Census 2011 which accounts for 8.6% of the total population of the country. The share of the Scheduled Tribe population in urban areas is a meagre 2.8%.

 Madhya Pradesh, Maharastra, Orissa, Rajasthan, Gujarat, Jharkhand, Chhattisgarh, Andhra Pradesh, West Bengal, and Karnataka are the State having a larger number of Scheduled Tribes These states account for 83.2% of the total Scheduled Tribe population of the country. Assam, Meghalaya, Nagaland, Jammu & Kashmir, Tripura, Mizoram, Bihar, Manipur, Arunachal Pradesh, and Tamil Nadu, accounting for another 15.3% of the total Scheduled Tribe population. The share of the remaining states / UTs is negligible. The Scheduled Tribes in India form the largest proportion of the total population in Lakshadweep and Mizoram followed by Nagaland and Meghalaya. There are about Madhya Pradesh has the largest number of scheduled Tribes followed by Orissa.

 

Bo tribe of Andaman & Nicobar got extinct in 2010, Jarwa tribe is facing a threat now due to Covid19.

According to the NFHS 4, 45.9% of scheduled tribe members were in the lowest wealth bracket compared to 26.6% of scheduled castes, 18.3% of other backward caste.

They are along with the rural population, on the frontline to face animal-human conflicts and increasing zoonotic diseases as they are core or peripheral forest dwellers. Their livelihood is unstable and their income comes in the lowest percentile

 They are in a transit phase from education, social status and practices, political power and economic conditions. This adds on to the subtle discrimination and inequality of the poor and rich, women and men, rural and urban, the elderlies and the youth communities in India. There are certain governance norms for tribals, with specific education, social, economic and political provisions as well as public health infrastructures norms, a Health Policy and Programmes are required to address specific disease burdens challenges of them.  

 Two Steps Backward: 2. Blurred preventive health and promotive health

 As per basics of epidemiology there is a Triad of Causes, curative care - clinics, hospitals, medication etc. can tackle the Agent factor, can alleviate the Host factor partially - effects of Agent factors, but cannot do much on Host and Environment factors nor can it control these other factors themselves becoming Agents!

 

It requires heath promotion and preventive health care. Nutrition status and food security, behaviour changes for nutritious food and exercises/sports, health communication and education, accident prevention, environmental health to prevent pollution of air, water, land, prevention of work stress and work related diseases, lifestyle based illnesses like high blood pressure and diabetes, reverting social determinants depression and suicides, domestic violence, child abuse all require social, environmental, economic, psychological and political preventive actions. That is missing. The tobacco chewing and smoking has been reducing thanks to consistent behaviour change communication, taxation and change  social norms could change the situation. Universal Imminization isn't enough preventive care for averting deaths and diseases as the Global Burden of Disease study, 2019 shows: (http://www.healthdata.org/india)

 While malnutrition as a risk factor has reduced, it is dietary intake which has added to the risk of deaths and disabilities. 

There are contradictions in India's progress in its Health status, in its infrastructure and in its health care system since Independence - it has achieved much, has to go further far more. It is a 70 year old republic sovereign nation, there are older than us nearby or other continents, we can set up health care system accessible and affordable to all, as some of the older nations like Thailand, The Netherland, Sri Lanka or Canada have done. There are visions, models, options available to us. Choice is ours! Can Covid 19 be an eye opener? 

    INTERVAL!

 Let us see....my next Blog - Blog Beta! 

What is to be done, for Public Health as self health and health care!

What Nolan shows and what I 'see' there...

And you, my father, there on the sad height,Curse, bless, me now with your fierce tears, I pray.
Do not go gentle into that good night.
Rage, rage against the dying of the light.

(Dylan Thomas, 1914 - 1953, read by Professor Brand shares in the Nolan's recent film "Interstellar")

When a friend shared this poem in an e-group, I was amazed about the antitheses within the reality - 'fierce tears', 'rage in dying light' etc. When I realized that this is the poetry shared on a Sci-Fi or (Sci-Real) film - Interstellar by Jonathan and Christopher Nolan, I said - oh, oh, so this is a new facet of the Nolans.

Before I start ranting, let me say that I have liked his Dark Knight Trilogy, Inception and of course, Interstellar. They are worth seeing, not necessarily to seek solutions of real life but to engage in a dream-come-true voyage while sitting on a seat with wafers in your hands.

So, here I go... What Nolan showed and what I 'saw' in the three fantastic films the Nolan's have made:

1. Dark Knight (2008) projected a fine line between heroism and activism - a self-motivated, dedicated, powerful, superior than the system person (Modi personified in 2008, but in the comic form it existed much earlier) fighting criminal calling himself a Joker (the black money holders, the terrorists, the chinese, the congress, the rapists, the cheaters etc. in today's context.). There are systems which are hidden and they do not create such blacks and whites although we all wish it should be. We yearn for saviors and remain watchers but are not doers. Somewhat a childlike complexity.

2. His other film is 'Inception' (2010) Very creative and ingenious. Dom Cobb is a skilled thief, the best with art of extraction, stealing important secrets from the subconscious during the dream state. Cobb's ability makes him a high value player in this new world of corporate espionage -  a system maker as well as a victim because it has also made him an international fugitive and cost him everything he has ever loved. So, he is offered a chance at redemption. One last job could give him his life back but only if he can accomplish the impossible-inception. Cobb and his team of specialists have to pull off the reverse: their task is not to steal an idea but to plant one. If they succeed, it could be the perfect crime. No perfect planning and management no one can predict what the corporate enemy would do because the enemy is also able to do so, except Cobb because of his skills of extracting secrets. It also comes back to an individual artist who can do the 'magic'. (A glimpse of the recent resurrection of Magical Realism - a miracle we all desire to happen, but know that it will never, somewhat making us numbed, anesthetized. It is not a technical skill, it is afterall a human skill.)  

3. Compared to Inception, Nolan's Interstellar (2014) is a deceptive, 'kneeling down' film. In the near future, Earth is devastated due to extreme climate changes leading to drought and famine causing food scarcity. (This existential approach does not look back as to who did it, what caused it, how we can/ could have prevent it etc. etc. Bhopal tragedy, 26/11 are redundant, a new, dark age is on but elsewhere. But where? No one knows.) When humanity is facing extinction, a mysterious discovery in the space-time continuum is occurred, giving human being an opportunity survive. Human race must go else where - out of our solar system in search of a planet that can sustain life. The crew of the Endurance should think bigger and go further than any human in history as they embark on an interstellar voyage into the unknown. Coop, the pilot of the Endurance, must decide between seeing his children again and the future of the human race. Again an avtar, or avtars thinking positively, thinking big and banking upon technology and traveling to the unknown - a blind move. 

The poem has context, that though we have given up and dying but keep your rage about it on and look for an alternative. Again, no analysis that why, who, what, when and how this defeat to nature was caused because it is not needed, be active and technology would save you! Savior is not a human being but the technology. 

This is the deception. Please see the making of Interstellar on youtube. (www.youtube.com/watch?v=ZjRmlTAjDI8) The amount of human efforts behind making it is tremendous, just an example - creating the wormhole and black hole, Dr. Kip Thorne provided pages of deeply sourced theoretical equations to the team, who then created new software programs based on these equations to create accurate computer simulations of these phenomena. Some individual frames took up to 100 hours to render, and ultimately the whole program reached to 800 terabytes of data. The resulting VFX provided Thorne with new insight into the effects of gravitational lensing and accretion disks surrounding black holes, and led to him writing two scientific papers: one for the astrophysics community and one for the computer graphics community. It was a collective effort which made a wonderfully creative new technology resulted in a deceptive film albeit with a scientific leadership with characteristic precision in making it happen. 

A lot to learn - an unlearn when out of one's seat...

http://sahajapatel.wordpress.com/2013/06/08/its-a-baby-girl/

इसने मुझे रुला दिया

जिनहे नाज़ है हिंद पर वो कहॉं हैं ा

Are 'Good' Practices after all really 'good' or just goody!

In this era of transition, (I don't know how long this transition is to last, or will it really last!)we look at practices which are good. I mean. look at the issue of malnutrition - we spend hours (governments have spent years) to ensure nutrition - to the deprived, the hungry with the aim of reducing their hunger, their appetite. Wait a minute, let me correct myself, we do it to reduce deaths - of children below 6, people who may die due to hunger! We do it to reduce IMR! Or thats what we measure to what we did was correct or not...

I have not heard of any feast, meal, parties which is designed for this purpose. We do it to satiate us, or those who are enjoying it! We measure by asking them,"Hope you liked it". Now, when I go around looking at the Anganwadis, I look at the register but no children. If I meet them I look at their weighing scale's face for their weights but not their faces - happy or sad!

So, now I have been having some 'dip-tinking' about the Good Practices in RCH I which we had studied. The document is available on linkage given on the left side.

It talked about activities which increased RCH's programme outputs. outcomes and impact. I am now rephrasing it as 'Good Practice Study for Women, men and children happiness!'I may restrict it to health services only but isn't joy and happiness is a part of mental health! I am sure the study would definitely reduce one type of death - the death of sensitivity!

Stray Thoughts: We need 3 (million) idiots!

I saw ‘3 Idiots’ at a conventional (not at a cinemax type one!) cinema hall.‘Vinod’ Chopra and Rajkumar Hirani once again pulled away the red carpet from under the elite feet. Space pen v/s lead pencil, electrified spoon as a ragging preventive mechanism, scooty v/s ambulance, theoretical v/s practical learning, cost v/s need etc. were demonstrated effortlessly and effectively.

‘Aliswel’ as the punchline has spread as a wildfire. (In the last few days, I have heard this phrase million time amongst co-travellers, roadside heros, co-eaters etc. Such non chemical anesthesia – a verbal acupressure at some day would be a refined art of non invasive anesthesia and I will not be surprised if clinical psychologists can also become eligible for an MD in this superspeciality. (They anyway deserve to be.)

We all have bumped into such idiots in our life. About thirty years ago, I and a well known activist were traveling on a mobike from Amravati to Nagpur. It was quite late in the night. Somewhere on the way, the mobike conked out. Plug, carburetor was checked and to our shock, we found that the floater had stopped floating! It was full with petrol. We cannot remove it and of course it needed to be soldered again. We decided to to dump it at a safe place. When we approached a local house, the farmer said, “Why don’t you consult a local mechanic in the nearby village. He repairs everything – a cooker, a stove, a diesel or electric pump, radio etc., etc..” Skeptically, we went to him. He was a 15 -16 year old boy! We told him the problem. With a lot of confidence he asked us,: Did you check the starter, battery and the plug.” We said yes. And showed him the floater. He said, “it is simple, do you have a matchbox?” My smoker companion gave him the matchbox. The boy gathered dry grass and lit them. Rotating the floater at a distance from the burning (rather just glowing) grass, he kept shaking it every minute. “The petrol would go out but the remaining solder would remain intact.” He said. In about five minutes the floater stared floating. Mentally, we were breaking our heads. My partner was a PG in Chemistry (this nacheez was also an inter science pass with chemistry as a subject!) and he knew about oil refineries and lead etc. but we never thought that burning grass would generate adequate heat which, if used cautiously can evaporate petrol without affecting lead! The 15 year old idiot (The Millimeter) did it! We reached Nagpur, about 100 km away safely without any stress.

Another example in our own field – the community health worker. A CHW - woman of about 60 or more year old. She belonged to a primitive tribe – Katkari. She was not trained with reading and writing skill but had developed her own system of memorizing medicines. During a monthly meeting, she shared her experience. As a part of medicine kit, CHWs had Gentian Violet as a standard drug for wound dressing. When a person with a wound under his left thumb came to her for dressing, she realized she did not have GV. She could not have been able to get it refilled because the whole community was working far away. She realized that the person needed an antiseptic medicine o be applied. So she prepared a paste using crushed and finely sifted sulfa tablet and oil! We had not trained her for using sulfa powder like Nebasulf etc. I asked her why sulfa. She said, ‘You had told us to use sulfa tablet for infected sore throat. Since the wound was also infected, I used it as a powder for dressing! (In the parlance of knowledge, she had reached the level of Application!)

We know of such great ‘idiots’ who have demonstrated changes even in our own fields. Fredrich Engels in public health, Florence Nightingale in statistics, Dr Jenner in immunization, David Werner in Rural Health Care System. They have demonstrated ideas and their application which spread like a wildfire. We have Collectives also - Dais for normal deliveries, Vaidus for herbal medicine or for that matter Dabbawallahs of Mumbai in Supply Chain Management, Bhishis in microfinancing are such examples. Incidentally, this film has been added to the syllabus of Management Science!

We need such idiots now for universal health care system. Today’s system is not easily available, accessible and affordable. Cost of health care is soaring up. We need them for ideas, not just 3 but many, many more. We also require a Suhas, who shouts at his fiancé because she loses a gift. Not because it is a valuable one but because it has a high price. After all, cost can be a concern.

Just a word of caution, however. The 3 Idiots have demonstrated that in unforeseeable situation their ideas were the best. But they are not always safe and appropriate. Bringing to a hospital, an unconscious person in a sitting position is not safe in every situation. But if no ambulance is available using whatever is available is better than not doing so. After all, before developing the Space Pens, conventional pencils were used. But there were flaws in them. The granite and so does the wood - break at the variable temperature in a space craft – 1500C in shadow and 1200C under sunlight. Broken pieces float in the space craft and can create a disaster. And both can burn in 100% O2 environment! (Please see http://www.snopes.com/business/genius/spacepen.asp) So, idiotic ideas should be tested – are they harmless or potentially harmful? So, we need a Silencer, too!

Moral of the story - Always say ‘Aliswel’ when you are applying an idea, even when it has been tested. After all, saying so is not harmful! Isn’t it?

My Walong Visit

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Some stray thoughts on professional teaching methods –

Nowadays, several of us are involved in training-teaching-learning processes. Whether, as resource persons in a workshop or as a trainer in a training session or module developers, we are in adult education. If we are not educationists, or not psychologist, are we competent? It is only recently that faculty development among health professionals has started but most of us become trainers on self learning or experiential learning methods. Are these only applicable as adult learners? I don’t think so. In fact, Julie Conlan, Sarah Grabowski, Katie Smith, Department of Educational Psychology and Instructional Technology, University of Georgia (Authors of Review of Adult Learning at http://projects.coe.uga.edu/epltt/index.php?title=Adult_Learning) also believe that these methods are applicable even in childhood.) My belief is on small experiences again at my school Sardar Patel Vidyalaya.

Some expirience of ‘experiential and self learning’

In August 1965, the India – Pakistan War broke out. We were early teen agers studying Social Science text book when the war started. A normal reaction of fear and excitement – of black outs, of combats and of war propogandas – was natural. Every morning there was siren exercise at the school ground. But, our social science teacher changed the syllabus and his role – he took permission to adapt the 6 months syllabus into Kahmir issues, Indo Pak War, the military structure, role of UN etc., etc. Sources was supposed to be magazines, newspapers, radio like AIR, VOA and BBC, some stories, II WW comics etc. We were to prepare a daily news item and inform the daily prayer session of the whole school! We had groups for projects – about the structures and strengths of Indian and Pakistani Armed Forces, about history of Kashmir issue, history of Indo China War etc. etc. For the first time the ‘boring’ subject became an exciting and action oriented one. The groups competed for better presentations and better knowledge. A group actually went and met some high rank in the 3 wings! Incidentally, the whole class passed with bright marks! Involvement of the children was high, converted fear factor into a creative one. Its imprint is still palpable – I can ‘see’ the face of Shri M L Sharmaji – my ‘facilitator’ cum teacher!

What I am saying is nothing new, all our eminent schools have this as a part of teaching method. I am questioning ourselves: do we have in medical, para medical education such methods? How much of our education is based on problem based, learner centered, experiential/action learning methods? To what extent are we flexible in teaching in the formal education system? A survey conducted among medical students by CHC a some time back had pointed out a similar problems.

My loud ‘diptinking’

Have we done so in our ASHA/CHW training? We stick to one approach, one manual and train the trainers accordingly and defeat the very purpose of flexibile, learner centric approaches. My dilemma is what to do can be fixed but can how and who be also fixed? In an action learning, there can be a group of learners and a facilitator/learner’s coach or counselor (in the Open Distance Learning’s parlance). The trainer can learn how to train while doing, so the ToT should be an orientation workhop and the real ToT should be while working as the facilitator and not in the classroom! Let there be an observer and review meetings for discussing the Pros and Cons, areas of improvement etc. Even comparatively less educated self learn, learn while doing but trainers are not so less educated. They are doctors, nurses, social workers who have their own experience, knowledge of education, knowledge about the content etc. How much of instructions would have retention when action is in different environmental settings required?

What are your thoughts? Experineces? Experiments?