Fixing the healthcare mess; Satyameva Jayate or showmanship?

Dear fellow Doctor; from your Facebook posts, emails to me and tweets, it is obvious to me that the Satyamev Jayate episode on corruption in healthcare worried you deeply. some of you were happy that such an exposé happened, but most of you were worried that there was over-dramatization and untruth in the presentation, and that this would lead to doctors loosing respect in the sights of their patients. As it is, India is known for its violence towards healthcare personnel, it is only fair that you feel that people would use this show as an excuse to attack more doctors.

I too, felt that many of the things Mr. Amir Khan said were unbelievable, some of them were clearly exaggerations and one-sided and I wondered about the truth behind the cases he presented.

But before we jump into another analysis of how Amir Khan got his medicine wrong, let’s look at a few other things.

Here is a list of some of the recent healthcare related scams and exposes that happened independent of Mr. Khan
  1. Senior Professors of prestigious institutions caught following orders from Pharma companies about drug safety reports to the DCGCI.
  2. AMRI, Kolkata hospital fire – revealed bad infrastructure, collusion of top doctors in hushing up things, lack of training and preparation in dealing with emergencies.
  3. Female infanticide – Millions of female babies are being aborted. A phenomenon Involving parents, Radiologists, Gynecologists.
  4. IMA protesting against nurses strike even as they support doctor’s strikes. This, in-spite of the horrendous working conditions and pay of nurses.
  5. MCI’s dissolution – It was so corrupt, that even a corrupt government had to agree.
  6. Surrogate mother industry – poor women being exploited, paid, but not as much as promised, not following international norms in number of pregnancies.
  7. Harvesting of ova- recent report shows how this is probably harming young girls without their knowledge.
  8. NRHM scam for which 22 doctors were suspended – INR6000 Crores is thought to have been stolen.
  9. Hysterectomy epidemic. – Need I explain?
  10. Illegal clinical trials and deaths from them.
  11. Reports of patients being affected from drug trials and not being compensated.
  12. The AYUSH report – No standardization, AYUSH doctors prescribing non AYUSH medication.

There are more, of course.

Let’s now look at the main points raised by Amir Khan in his program; not specific cases, because he is not a doctor and is not qualified to make judgment calls on treatments given to patients. Let us just look at the basic complaints patients had.

  • There is lack of communication between doctors and patients. They don’t feel like they are part of the decision-making process about their own disease.
  • There is a lot of bad handling of deaths, accidental deaths etc. News not being shared, defensiveness, etc.
  • Actions of many or some doctors is leading to a wide-spread distrust or doctors, more so because if you go to 2-3 doctors for the same problem, they often suggest different treatments
  • Issues with improper consent taking and explaining of need for surgeries and other procedures.
  • Lack of information about what a hospital is licensed to do, what training doctors have, and the fear that people without sufficient training are treating them.
  • Referral fees, cuts and other forms of bribes paid to doctors affecting medical judgment.
  • Money being a major deciding factor in issuing medical college licenses and other kinds of licensees.
  • Bad policing by medical bodies leading to un-checked unethical and bad medical practices.
  • Too much power held by private players who don’t care about medicine, just profit.
  • For the government, healthcare spending seems to be low priority.
  • Poor get differential treatment.

Is any of this fabricated or unreal?

They are real; you and I know this.

We are poor communicators, busy as hell, running between wards and OPD or from one clinic to other, often we just cannot find the time to sit down and explain things to each patient. There is also the problem that what we think is communication might not be what the patient wants, and our training does not really help or prepare us to communicate better.

All of you have heard stories, of patients being admitted into the ICU for what turned out to be gastritis, and probably seen patients who have had two cholecystectomies and appendixes removed from both sides of the body. This happens, a lot, and it is a frustration we all share.

How can we reconcile with the fact that an unknown, but very large part of healthcare practice in India has a less than ideal or even acceptable level of quality and that the system is designed not for the patient, but for the professional?

While we mull on that, here are some things he got wrong, in brief.

  1. Using branded expensive drugs and not cheap generics – Not all drugs have generics, not all generics are tested, and in many instances there is significant difference in quality. There is also the patient’s expectation to use standard medicines. Much as I hate them, I can trust the quality of medicine made by a large pharma company, how do I trust a generic?
  2. Healthcare as a business is not necessarily evil, and the solutions that were put forward, including making everything government run is simply out of touch with reality. Your neighborhood green grocer is a businessman; this does not mean he will sell you poisoned vegetables if it gives him better profits. Businesses can be run ethically, and markets have great power of self-regulation.
  3. Doctors have a right to livelihood. Just because we are doctors, to expect sacrificial living is ridiculous. If indeed, as Amir Khan suggests, we are the smartest of the lot, then we deserve proportionate incomes.
  4. Doctors control only a part of the healthcare system; costs of drugs are for most parts out of our control, as are institutional costs. Blaming doctors for high cost of drugs comes from not understanding the basics.
  5. Doctors have an exalted position, but this kind of a mess could not have been created without collusion and involvement of regulators, businesses, government, other members of the medical team, and the market. Blaming just us is myopic.
  6. “Most doctors in India need to get their licenses revoked” is an unforgivably careless and unsubstantiated claim. While I don’t want an apology from him, Mr. Khan should know that it only displays his ignorance.
  7. “Will not see a doctor in India” What about Devi Shetty? Again, a very careless thing to say, but hey, it’s his choice. There are people who don’t want to vaccinate their kids, some people even say this on TV, but that is their choice, their life.

Back to the show.

Most of the reactions against the show hinged on one of the cases discussed in which there was ambiguity about the process. In this clamor to prove that Amir Khan got his medicine wrong, we forgot and ignored the other stuff, the stuff that I listed above.

Dr. R Srivatsan, Senior Fellow at Anveshi Research Centre for Women’s Studies wrote this in an email when this episode came out:

I think when a critique is mounted against you, it is important to look close and hard at yourself and the community you belong to. Where there is smoke, there is bound to be a fire you don’t want!  Most often people don’t have the time to bother to criticize you — except when you cause a great deal of pain.  Criticism is an opportunity, a possible door to transform a process — it has to be nurtured, not snuffed out with hurt defensiveness.

Could we benefit from such a show? Can we use this time to weed out or at least distance ourselves from those whose practices all of us find distasteful?

Doctors are at a particular advantage here; it doesn’t matter how famous Amir khan is, it doesn’t matter how widely his message reaches, people still need doctors. Maybe we can use this as an opportunity to make things better.

Let’s agree to this:

  1. People who were on the show are real people; I think it is safe to assume that they were speaking their truth. Even if one of them was not, there were others who were. They don’t need to speak untruth because there is no lack of bad diagnoses being handed out. We need to live with the fact that there are unscrupulous doctors, and we all know people who fit the bill.  Protesting this fact is only helping them.
  2. Amir Khan is an actor.  He runs a reality TV show. He is not a scientist, has no background in public administration, and the show is not a journal nor a scientific exposition. There will be things wrong with the show. He will get facts wrong. Have you met people who spend their Sunday morning reading out the Journal of Industrial Biochemistry to their families? Didn’t think so. Facts are often boring, Mr. Khan will try to make them attractive and sometimes, the real face will get buried under the make-up.
  3. No silly excuses. Some of you made what is possibly the silliest of excuses, ever. “Everybody is doing it, why target Doctors?” SILLY. I’m going to let you figure out why.

We work long hours, the pay isn’t amazing, the system is corrupt, without cutbacks and the pharma parties, life would be tough. We want that to change, we want to practice great medicine and have a life.  We want pays that are proportionate to our effort and attainment, we would like to be respected and acknowledged for the good work we do.

How is cursing Amir Khan helping us achieve any of that? What will help? I think we know some of the answers, not all of them. What are they? Lets talk.

Introducing What’s Up Doc? A column at eSocialSciences.org

I am giddy with glee to announce that I will be writing a monthly column about the practice of medicine and related issues at eSocialSciences, a “region-focused repository and a new and yet evolving publication space for easy and quick dissemination of scholarly work that can be a space for discourse among researchers, policy makers and the civil society.”

This month’s column is about communication and medicine. Medicine is all about good communication, they say, yet, very little is said or taught in most medical schools about how to be good at it. Do read and comment.

“Be nice to patients”: Communication and Practice of Medicine.

Medical school began with a series of “introduction to medicine” lectures. One of them was on communication, taught by the same professor who introduced us to medical ethics.

 

In the medical ethics class, through a case-discussion, she impressed upon us the need for being non-judgmental when dealing with patients. She did a fantastic job, considering she had just one 45 minute lecture. Her lecture on communications, though, is a blur. In my defense it was 11 years ago and I remember her parting words very well. When we told her after the lecture that there was just one session on communication and this clearly needed more sessions she said “I’ve been telling them, but who listens to psychiatrists?”

 

Doctors and other healthcare professionals, I would love to hear more from you about this, and related topics. Do comment.

The Devotion of Suspect X By Keigo Higashino – Book Review

The Devotion of Suspect X

I asked to review The Devotion of Suspect X by Keigo Higashino in spite of not being a fan of modern murder-mysteries. Here is why “…..won the 134th Naoki Prize , the 6th Honkaku Mystery Grand Prize, 2006 Honkaku Mystery Best 10 and Kono Mystery ga Sugoi! 2006, annual mystery fiction guide books published in Japan, ranked the novel as the number one”(Wikipedia). I’ve read only serious books for a while now and thought an international whodunit would make a good change.

This novel is part of a detective series in which an assistant professor of physics, Manabu Yukawa, nicknamed “Detective Galileo,” helps his college friend, Detective Kusanagi of the Tokyo Police, in his investigations. Manabu is portrayed as a hard-core scientist, a genius whose ability to logically solve problems is unmatched. Yes, a gainfully employed Japanese Sherlock Holmes without the flair and cocaine. The story is a cage fight between a physicist and a mathematician, and what happens when unforseen variables are introduced into an otherwise perfect equation.

In this story, he stumbles across his college friend Shinji Togashi, who is somehow involved in the latest case.

It is a short, absorbing read, even though not as “thrilling” as a western murder mystery would be, nor as laid back as Poirot was. Yukawa is a brooding-brilliant man and Detective Kusanagi is a sharp typical copper.

The story begins when, Yasuko Hanaoka an ex-hostess accidentally kills her abusive ex husband who had been stalking her and threatening her daughter. Togashi, who is her neighbor and has a crush on her hears the ruckus and comes over and helps them clean up the mess. He tells them that he would “take care of everything” and they just had to do as he said. Togashi who we later discover to be a mathematical genius spins a “perfect formula” to ensure that the police cannot catch Hanaoka for the crime.

The police and Professor Yukawa come into the picture when an unknown man’s body washes up on a nearby river’s bank and some snooping by the police reveals its connection to Yasuko and later, Togashi. The author has done a fantastic job at leading us on, unraveling a mystery we think we already know an end to.

The clue-deduction chain is almost perfect, yet mysterious enough to leave us guessing till the end, when Yukawa makes a crucial decision about his friend’s guilt based on a passing remark by Togashi. That was a leap of faith and far too crucial for the story to be taken lightly, and it almost spoils the ending, but a twist upon a twist that the author delivers, even if predictably melodramatic, saves the ending.

In all, it is a well written story, good detection, a few plot-holes but saved by drama. Not extraordinary, but above average.

Note: I received this book from Blogadda for review.

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The success formula- Shyam Benegal on Hindi Cinema and the challenges of New cinema

The cinema situation : A symposium on the struggle for a genuine approach

In 1977 there was a symposium examining “THE CINEMA SITUATION”. The symposium was attended by some greats of Indian Cinema like Mani Kaul,  Kumar Shahani, Adoor Gopalakrishnan, Shyam Benegal etc.

I discovered a quote from Shyam Benegal’s essay on tumblr via Dhrupad and was hooked. I discovered that the quote was from a longer essay on the formulaic nature of Hindi cinema and the problems new cinema was facing and some solutions. I have a 1400 word long excerpt from that essay, which you can read in full at the above link. But before we jump into Shyam Benegal and his lovely essay, here is the symposium’s topic defined.

The problem

India’s film industry has manufactured and peddled over many decades a distinctly unique commodity to a wide and unsuspecting audience. Based primarily on fantasy, it has mocked at every value in a richly diverse culture. Mock heroism, mock sex, mock dancing,mock singing, mock religion, mock revolution — the lot. In its end product, it has shown the degree of degradation to which a transparently synthetic approach can lead. Its influence on society has been startling — in dress, styles of living, methods of working and,most shatteringly, in the dreams and aspirations of a deprived people. The bizarre world of the screen is the world to reach for. Unfortunately, this commodity faced no challenge of any stature until the arrival of the new Bengali film under Satyajit Ray. His Pather Panchali showed that films could be made with little finance, and no stars, and with integrity. Since then, there has been a gentle struggling, a push here, an upsurge there, a raising of more authentic voices, the slow birth of an indigenous cinema. But, it is beset with problems. Finance, distribution and, infinitely more serious, that of communicating in a medium which is not mock fantasy any more. For, the audience has come to regard the film as synonymous with a particular breed of song, dance, vulgarity, burlesque, violence, crudity, escape, often under the mush of misleading progressive situations — rich man poor girl, rigid father growing son, erring husband devoted wife, etc. Is it ready, even in small measure, to receive a new experience from a familiar medium? If not, then how can the struggling new cinema survive and break through an obvious initial rejection.

The success formula Shyam Benegal

The success formula by Shyam bengal

THE Hindi film business ,in India consists largely of working out the equations to make commercially successful films and then to work out a strategy of publicity and distribution to fake in the largest profits possible—a vast, speculative activity that begins with formulating and analysing the success of any one or more films running at any given time in terms of what makes them tick, which usually means the right mix of ‘ingredients’ such as stars, songs, and music, the plot innovations and a generous helping of what are known as production values such as enormously expensive sets and property, lavish public relations’ devices like parties replete with cabaret items in five star hotel suites.

There are storywriters who will produce on call’ several plot lines lifted from successful films, mainly from Bombay and Hollywood as well as from popular western writers like James Hadley Chase to produce a biryani of a film all ready to be hogged by the film-going public for 50 weeks or more in cinemas all over the country. There is a huge demand for well-known stars to act in these films and for music directors to turn out their lilting songs, and for dancers to give new, sexy turns to’ their cabaret items.

The directors who direct them are recipients of paeans of praise for their originality. The producers are the happiest with their success and end up signing up more and bigger stars for their next ventures as distributors willingly take even greater risks by committing larger sums of money for each territory. The pattern of business points to an industry that is happily and profitably stewing in its own juice.

There are several kinds of success formulae. Each one is specifically categorised, such as social drama (meaning poor boy/rich girl or vice versa), family drama (lost child, suffering widow, large doses of amnesia), action movie (good man-turned-bad dacoit-turned-good man), historical (now not much in vogue) or mythological (generous helpings of sex relating to gods and goddesses). In each category, the need is for the biggest star or stars. If you can afford it, you would have all of them together. The music director is chosen according to the size of his contribution to the latest hit songs (do I hear a resemblance between his tunes and the top-of-the-pop in London?). Similarly, the ace writers. Writers, of course, do not really write. They sit in posh hotel suites and narrate scenes for the next day’s shooting.

It is an expensive and serious business. Very expensive. And films flop. Despite or, perhaps, because of this, the Indian film industry ticks. Flop is a relative term. Very few films are known to fail altogether. The only thing that might happen to a film is that it may recover its cost over a longer period of time

Shyam Bengal in his Office
Shyam Benegal 2010

The serious problems that beset the industry are the highly inflated rates paid to the marquee names in the film—the stars, the music directors and, recently, the music directors. There are stars who sign up for as many as 50 films at a time. Logically, it would take him or her about ten years or more of work every day to complete so many films, but they are signed up nevertheless. Similarly with music directors. The chances are that a lot of money spent on such films will prove to be irrecoverable because the films are not likely to see the light of day. And whatever is spent in signing up to start the film will be lost forever. This constitutes an enormous waste. Then,again, there is the matter of dates.

It costs a lot of money to set up a shooting schedule. In this situation, if a star cannot give dates the entire expense in mounting the schedule is lost. The stars themselves under these conditions tend to develop an inflated sense of their own importance. They feel
no obligation to keep to their schedules, nor do they feel the slightest compunction to break appointments—a bit like successful politicians. They appear to follow no normal set of rules.

Again, there is a reason for this behavior. Most producers have no money to begin with. They trade on the names of stars, music directors and writers to raise money. The stars are generally very insecure, never sure that any of their films ar going to be completed. They cannot possibly take the risk of signing just one of two films. if the films do not get off the ground and get stuck mid way they are out of jobs. Nothing is worse than an actor without a job.

The distributors who market films have defined their films as those meant: (a) for the masses, (b) for the classes, (c) art films that will attract no audiences. The films that are likely to be the biggest successes are the ones made for the ‘masses’. They could be defined as films that are utterly naive in their story content, with non-existent character development and two dimensional emotional and intellectual attitudes.

Films that will fetch the highest price are the ones that have the largest number of stars, a storyline replete with what are now essentials — thrills and chills, rape scenes, dance numbers and cabarets, choreographed fights and comedy. (There are specialists who are known as ‘thrill masters’ apart from ‘fight masters’ and ‘dance master’. Soon one expects there will be ‘rape masters’) Brilliant colours and sharp cutting is a must.

…….xxx…………

He goes on to talk about the costs incurred by producers in a typical film and establishes the reason why the films are shot they way they are.  Then he moves on into the need for a sustaining structure for alternate cinema

…….xxx……..

If we are serious about developing an alternate cinema, the FFC would have to develop a distribution circuit that is able to compete for audiences with the regular so called commercial films. In addition to this the cost liability for the production would have to be borne

Censorship

A more insidious development in films has been caused by outside factors. Paternalistic and straight-laced censorship has made film producers increasingly irresponsible. As we all know, authority of a certain kind often creates an irresponsible attitude in those who are under it—they expect to be corrected rather than correct themselves. This has become so acute, that many films only attempt to push in directions in which the censor board is likely to be heavy-handed, only to check out how far they can go. Often, the only innovation in a film comes in the techniques to project ‘soft’ pornography or violence that would catch the censors napping. This has led to the making of films which encourage ugly social attitudes, particularly between men and women. They are done with such crudity that one wonders whether those who see such films come unscathed out of them.

As is well known that with cinema, particularly when it happens to be the only entertainment medium, life starts to imitate film. We have only to look at those parts of the country where film is the only entertainment, medium to see that this is true. The way boys regard girls, the way they dress themselves, the kind of music they enjoy most, the speech they use—and with the new-rich—the kind of interiors they have, replicas of film sets.

Yet. with all this, a different kind of film also runs. Audiences will see films that reflect social realities. All that it requires is the kind of distribution which the commercial industry provides. The movement has already started. What is needed is the infra-structure that will make it self-generating.

Indian film or, more particularly, the Hindi film, from its very origin has developed its formats’ from the existing theatrical forms. The songs, The dances, the main plot and its comic parody, have all been absorbed by the cinema. If the alternate cinema has to grow, it cannot ignore these factors^ An extension of these forms is needed rather than unfamiliar ones and a far truer depiction of social realities. Only then will it be able to seriously compete for audiences. Short of this, the new cinema will be guilty of producing films for the sake of a small cineaste elite

Expertise, politics of health and the Doctor as an Educator

This post is culled from an exchange in a medical group I am a member of. Mr. Srivats has kindly granted my permission to reproduce this gem of a letter. Pay particular attention to the last 3 paragraphs.

Dear Friends,

As I promised in my previous mail, I am adding to the question of the relation between expertise and the politics of health care based on the progression of the Gentamycin – Co-trimoxazole debate. I would remind those who don’t know me, that I am not a doctor, I have little knowledge about these drugs, or drugs in general, and my intervention is related to precisely how to negotiate expert knowledge and a democratic form of medicine.

The specific case here is the exchange between Drs. Sri and S about the pros and cons of discussing such a complex issue in a public forum. On the one hand, I am able to see entirely the validity of Dr. S’s concern that imprecise knowledge and opinions can result in confusion, especially in a multilayered group like the xx egroup. On the other hand, it is precisely the question of expertise and the need to give direction without causing confusion that runs against the problem of a democratic medicine. Should we prevent confusion? Yes, if possible. Should we discuss the matter openly with a group that doesn’t have expertise in the matter — Yes, certainly. Whether it is the case of medical intervention for babies or nuclear power at Koodankulam (I am taking this comparison because of the expert dimension and impact on populations here too), the answer has to remain positive. How do we resolve this dilemma? Not only at the level of health care professionals, but also at the level of patients and communities.

This is where I feel that the position of the doctor as an educator must be examined. Do we have general discussions with parents and the community about giving injections to new-born children? Or oral medication? They certainly won’t have any expertise but they will know what the baby is actually going through on a 24×7 basis. I also have it on some authority that in the rural areas and perhaps among the poor in general, injections are a sign of a ‘good doctor’. It is therefore likely that they would welcome injections for their children without in any way of knowing about the risks and consequences. But I feel since the risk is theirs — their children’s lives to be precise — they should know, confusing or not. I will stress here that there is no point in romanticizing the people in the neoliberal mode — ‘people know best and they must make an informed consent’ — as we all know from the clinical trials scenario, informed consent is a travesty of the right to know what is being done to your body. Yet, I can’t help feeling a discussion must begin, with a democratic education and consciousness raising practice among committed medical professionals. I hope this doesn’t sound like preaching — it is more an exploration of possible avenues for a critical medical practice.

About toxicity and side effects too. This is a general aspect of medical care in its history — the positive iatrogenic effects of medicine (i.e. not the failures of medicine due to bad practice) but the costs of the successes of medicine in patients lives and health over generations of research, shots in the dark, and development. In the final analysis it simply isn’t enough for the doctor to decide that a particular percentage is below the threshold of significance and that therefore the particular medicine can be treated as safe. How can a democratic medicine begin to function in such a way that people know about the risks they take. And yet, I am aware that the general consensus (and medical science’s opinion) is that such an approach is impossible, but isn’t such a conversation imaginable (at the simplest, individual level, and at a much more sophisticated community level): ‘One in ten thousand babies who are given this medicine die, however, it is also documented that the following benefits do occur to the majority who are given it — do you want to take the risk?” to which the parent replies “No” or “Ok, Inshallah!”

It is perhaps likely that doctors who ask these questions will lose their practice to the confident practitioner who simply goes ahead and gives the injection or the tablet — but that raises another problem. How do we educate people out of this blind faith in the expert? The question is how to make the engagement with the doctor a face to face encounter, rather than one of command and obedience.

Would the members of xx feel it is necessary to pioneer this difficult political practice of a critical democratization of expertise? Not in the sense of making everybody technologically equal, but in the sense of teaching people to think about a decision making process on an issue that has bearing on their infants’ mortality (or any such issue of medical care)?

R Srivatsan
Senior Fellow
Anveshi Research Centre for Women’s Studies

Take home messages for Indian activists from KONY2012

As far as metrics go, Kony 2012 was a success. some 10 million people have watched the video and I don’t know of another social justice issue that so many people have heard of, let alone watched a half hour movie on.

As far as the production goes, KONY2012 was a job well done. I don’t have the metrics for how many people watched it the whole 30 minutes, but even if half the total number did, they did because the movie was made well, it was gripping and reportedly moved millions to tears.

 

If all publicity is good publicity, there never has been a better justice campaign like KONY2012. The white house has taken notice, as have governments in many places.

Also, if the age-metrics of Youtube are taken into consideration, a remarkable number of young minds have been made aware that young children like them are living in awful conditions in this world and that they can, and should do something about it.

But

It was discovered that people closely associated with KONY 2012  have also been instrumental in arming the present regime, which is as despotic as Kony was.

The campaign turned out to have a specific political aim, which it disguised as a human rights issue.

It fed the white savior industrial complex and hid a lot of information that would have caused people to think and be better informed.

It lead to nothing more than ‘awareness”. Kony is still free, and will be for the forseeable future

So

Success or failure, it is worthwhile to learn something from Kony

People care about other people

People can be manipulated easily

For something to go viral, you need to do a lot of background work, call it creating a tribe.

If your message lacks a call to action and a way to act, it will eventually be forgotten

You might be successful at manipulating emotions, but it is likely to come back to haunt you.

Childhood sexual abuse: be prepared.

It is time we face the fact that the sexual abuse of children is not an  occasional deviant  act, but a devastating commonplace fact of everyday life” Florence Rush The Best-Kept Secret

Sexual abuse of children happens. It is common and widespread. Like last year, a bunch of volunteers have been spreading information about childhood sexual abuse this month. I hope you follow  @csaawareness  on twitter and their website. On the website you will find interviews with experts in the field of sexual abuse, as well as links to posts by other bloggers on the issue.

child sexual awareness moenth
image from alternative.in

 

Some Characteristics of CSA

Lack of consent

Children cannot grant consent about sex, not because they are ignorant, but because there is no equality between them and an adult, and consent for sex can truly only be given between people on equal footing.

Exploitation

Any sexual contact between a child and an adult is exploitative in nature, Children are manipulated or coerced into sexual behavior by adults who are stronger, more resourceful, and more knowledgeable. They may buy the child

gifts, may persuade the child that all parents teach their children about sex, may threaten the child with punishment or more.

Ambivalence

Children are often found to be ambivalent about what’s happening to them, many don’t understand whats happening. Most know that it is not good, but since they are in a vulnerable position they cannot do anything about it. The sexual acts might be physically pleasurable, and this adds to their confusion, to which they react with ambivalence or by pretending it is not happening.

Force

Children are forced to participate, this can be physical force or more commonly by manipulating children’s emotions and beliefs. They can be threatened, or promised rewards.

“….killing an animal in front of the child and telling her that the same fate awaits her if she does not cooperate, threatening to abuse other siblings in the family, or suggesting that the family will be broken up if the child tells anyone.”

Secrecy

This is related to force, in that the child is also convinced that if he or she speaks up about it, something horrible will happen. eg. Family will break up, mom will leave us, no one will believe you etc.

Sexual abuse accommodation syndrome

is something seen in children who have been abused, they develop a group of beliefs and behaviors described as secrecy; helplessness; entrapment and accommodation; delayed, unconvincing disclosure; and retraction

Whats this information for?

The reason I just described these is to give you an idea how difficult it is for the child to come out of such a situation. This is also why it is very important for parents to start talking boundaries with their children very early. Most experts agree that as early as the age of 3, one can tell a child that the parts covered by her underwear or if she is taught names of her private parts, those, are private and no one should touch them, and if someone does, they should tell their parents, or another caregiver immediately.

This talk at 3 years, of course wont happen if parents are otherwise not open to talking about sex. If you cannot talk to your partner about sex, boundaries and what is acceptable and what is not, it is unlikely you will be able to do this with your child.

If both parents are caregivers, it makes sense to have early talks about sex and boundaries with both parents present.

The house also needs to be a safe space for the child, if when the child complains about other things, or stands up for herself in other occasions but parents respond with anger or ridicule, she will not be comfortable talking about something so sensitive.

Summary

  • Teach your kid to say no, early on
  • Teach her what other people are not allowed to do
  • Prepare with your partner/spouse before you have a child
  • Be supportive and a trustworthy parent in everything, not just talking about abuse.

I dont want to repeat what various bloggers have already said, and here are some for further reading:

If you are a survivor of abuse and want to talk about it, I would love to listen, as would others. If you are a parent who would like some more info or help with talking to your child about this, write to me or the good folks at CSA Awareness month.

Long-form Indian writing- Digest 002

I’ve been trying to find bloggers who write longer posts, and am happy to feature a few today.

My child’s spirit is just as important as her physical health.

Karina Varma (BziB on twitter) and her daughter had a not-uncommon horrific experience in a hospital. If you are a healthcare provider or a parent, this post if of great importance to you.

I have never forgiven myself for those forty five minutes when I let someone tell me that being a mother made me inadequate for a particular situation. But it was an excellent lesson, one that now makes me rabid about every single detail of my child’s care. I no longer accept everything her doctor says. I question everything now. When we went in for a follow up, the first thing we asked him was, if the need ever arose again would he consider us taking her to another hospital. He agreed. He even helped us with names of doctors in other hospitals whom we could meet with and decide on. See why we like him?

Notes from a script lab – Which side of the river do you want to be on?

So what happens in a script lab? Does it really help? If so, in what way? – These are few questions that i have been asked many times since i attended the NFDC-Locarno script lab. Have been thinking about writing a post for a long time but never managed to do so. And so here’s Vikas Chandra‘s post about his experience at Mahindra-Sundance script lab. His script Toothache was one of the eight scripts selected for the lab this year.

Vikas Chandra (@vikSchandra) describes his experiences in a script lab, this is great advice for not just movie makers, but anyone who wants to craft a story.


Ignobel Indians

We might not be winning any Nobel prizes but there is no drought of Ignobel winners from India, from formulas to calculate elephant body surface areas to the physics of hoola hooping. Priyanka Pulla in Open magazine.

Leaving love out in the cold

The playground is indeed the best place to get a glimpse of who your kids are going to be when they grow up. It is also a place to reexamine your filters, clean out the cupboard of your prejudices and open up your world to the lacy fan of possibility. On one such evening, as I watched them, I saw a bunch of kids ranging from 4.5 years to nearly 13 snicker, look goofily uncomfortable and exchange looks with each other when my little girl said “I love you, don’t go” to one of the kids.

Is your child comfortable in identifying what and who she loves? Sandhya Menon tells us about her princess.

Long-form Indian writing- Digest 001

In my last post I outlined that Longform writing on the web has found a new life thanks to apps like Readability, Instapaper and Longreads. My interest lies in finding indian writings that are long from and bring to focus my immediate surrounding. Every week I will present that weeks finds, and hopefully this list will grow as time passes.

Mumbai: Cities within

Sanjay Sipahimalani (SanSip on twitter) hosts a book-review carnival with around 10 recent books that are written about Mumbai.

It’s a chemical romance that begins and ends with the word “Bombay”, where all manner of depravity arising out of addiction is on parade. When the novel moves on from the Seventies in tracing the decline in the characters’ lives, you find an elegy for an earlier time: “Already now there were times when he could feel it slipping away, a way of life vanishing as he watched, the pipes, the oil lamps layered with years of black residue, the conversations that a man would begin and lose interest in, all the rituals that he revered and obeyed, all disappearing.”

He goes on to review Tajmahal Foxtrot, The Extras, Behind The Beautiful Forevers and more books.

A few God Doctors

Dilip D’Souza (DeathEndsFun on twitter)  takes us to the Ganiyari in rural Chattisgarh to a unique hospital. Here, around the year for close to a decade passionate Doctors from AIIMS and other top medical colleges work. The hospital is owned and run by a collective of locals, not by the activists who began the hospital. Some of my mentors and personal heroes work or have worked in this hospital, and so it was a delight to find a lovely long article on it.

As they work, the doctors keep up their steady discussion about what to do next, what drugs to give her. I know the two senior men especially, have years of training and experience to call upon. Even so, the impression they give is of addressing the situation not with jaded formulae from medical school, but with fresh minds, thinking on their feet. While their calm professionalism is impressive and reassuring. I cannot help a quick thought about the difficulty JSS has in attracting talent.

Conditions in Ganiyari are hard, the pressure is relentless. Nearly every day throws up fresh crises that interfere with plans for meetings, training programmes, or documentation. The pressures of their work often travel home with them, and there are the usual issues to think about; of the kids’ schooling, and indeed of life itself in this dusty backwater of India. These doctors gave up the chance of high-profile urban careers to come here, to work like this. And when they respond to this poisoning emergency, you can see why.
Hard work it might be, but it is greatly fulfilling too, working among the people who need their care the most.

 

Some you choose, some life chooses

Shubhra Gupta invites us into her home and tells us about her son who is autistic and what autism means to them. Reality is grim and gritty, and yet, humans find reasons to rejoice. She wrote this in the context of the World Autism Day.

We coast on little joys. He is a powerful swimmer, a fish in the water. We put him on a horse in the nearby stables a few years ago. A few weeks ago, I saw him trot, minus the stable lad, who has always had to accompany him till now; he sat upright, smiling widely, having a blast.

He has learnt to be very clear about his needs: not a silly burger, a pizza, okay? And he is on the whole, despite the now occasional meltdowns, a sunny, cheerful child. When he says a new word, it is celebration time. When he turns around and says good night, without having to be prompted. Or when he waves bye, and races off for his evening out. Little things, but for us, huge steps.

In our sobering moments, we are forced to introspect—what has all this meant for us as people, as professionals, as a couple. There is, of course, the cumulative wear and tear of bad-hair days. Sometimes just a few horrible seconds can be enough to wipe off the strength to face a working day.

Introspective confession of a silently fiddling worker ant

Dr.Swarna Rajagopalan (swarraj on twitter)about her journey as a worker ant in the world of politics and policy

And then at some point, something changed. The world became grey. Daily news became miniscule data points on longer-term perspectives. Outrage faded into observation. Opinion was replaced by study. I guess one way to look at it is that I became an academic. I do have strongly held values, but they became somewhat meta-political. What I am trying to say is they held in a place that was above the daily world of petitions and polemics.
….
The grey universe of the worker ant is strangely similar to that of Nero, who fiddled while Rome burnt.

The Language of High Art

Deepanjana Pal (dpanjana on twitter) discovers a new app that decodes the mystifying gobbledygook that comprises most curatorial notes in our biggest art exhibitions.

The Wall Text:

Art for Bose is a site of contest between context, subtext and pretext. Rather than passively see Banana: Braque, Warhol and Beyond, the viewer is encouraged to encounter the works and engage in the dialectics that inform Bose’s praxis. Bose’s work is part of numerous prestigious, international collections and thanks are extended to the following for their generosity….

Translated for the Critic:

Has thesaurus and isn’t afraid to use it. Photographs, paintings, sculpture and installation. Either the artist has studied abroad or has hired a postgraduate student to write wall text. Can use phrases from wall text if writing a review. Postmodern wanker.

Also featuring translations for Artist, Critic, Gallerist, Aficionado, Collector and Random visitor.

……

I hope you munch on these over the weekend.

Mail me at uberschizo at gmail with your favorite long-form writing from an indian author or tag me in your tweets on twitter. I am uberschizo on twitter.

Reading: Help a logophile out please

These last few months when I’ve been bed-ridden and vacationing, I read for over 8 hours a day. Yes, I counted.

I love reading long articles.

Most websites are not designed to help you with reading long form articles. Till Readability happened, I would tweak websites via firebug to make long articles readable. Readability has changed everything for me. One click and 2000 word articles in NYRB are not an eye sore.

I cant find Indian long-form writing easily

Yes, Caravan tries, ugly typography notwithstanding, but I have a suspicion that the best longform writing by Indians on the web happens in blogs. Are there other outlets? I know about Longreads. I was thrilled to find a movement that cares about reading. I even have my own page on Longreads. But Longreads, now, is all about American/British writing.

Help me out here

I care about the beauty of the writing. I care about what you have to say. I like writing that goes beyond the usual conclusions. I know this country is messed up, I know women are treated badly, I know healthcare sucks. Stating that much is not enough. Tell me a story. Or give me a new idea. Say something hilarious or outrageous. Make me think. Please.

I will help you

On my blog, I will run a regular digest of such long reads. I will also tag them with #longreads or #longreadsindia on twitter.

Oh, and spare me politics.

Thank you.

Anand

Long-form, for the web, is anything 1500 words or more but not 6000 words. Plus/Minus 10% is fine.