Digital health – Don’t throw the baby out with the bathwater

Dr. John provided us with an excellent summary of the ills of the specialization/hospitalization system in his article here. A summary of what he said is: Provide good primary care, not flashy (digital) solutions and tertiary care complexes. 

There is no doubt that primary care needs to be the foundation of good healthcare however, it needs to be said that that there’s an unsolvable manpower problem with the traditional approach to healthcare, and primary care in particular.

1. We’re producing world class doctors, but not even close enough in numbers to meet the needs of our country, even if they were somehow distributed rationally in primary care.

2. We need to think beyond the doctor, as she is only a small part of the system. Utilizing nurses, health aides and even patients and patient communities themselves in delivering healthcare is essential. There are ample examples from various parts of the world that demonstrate the effectiveness of this approach

3. Even if we were to restructure healthcare delivery to utilize every link in the chain, from patient to super-specialist, there’s still a significant manpower crunch, as even a cursory examination of the NHS primary care system will inform us.

4. The App mania has indeed taken the focus away from improving access to improving comfort, but the two are not mutually exclusive, neither does it mean that that’s all digital health can do.

5. The manpower problem, along with the knowledge problem, which is a discussion for another time, can be significantly reduced by investing in relevant technologies. This again has been well demonstrated.

6. Technology can only provide solutions to problems it is trying to solve. The overwhelming mandate of the digital health market is “make life easier”, not, “make healthcare accessible”. This lies at the core of  why all this big talk in digital health often does not translate into improved healthcare immediately.

7. In the end, it comes down to incentives, neither corporate healthcare in India, nor the larger public/govt health system in India is investing in creating such solutions, or providing incentives or environment to technologists to work in this field.

Till this shift happens, we’ll keep pining for solutions that no one’s working on. 

This post was originally posted on LinkedIn

Rape culture

And why we should care

Inspired by a recent post that explained Rape culture very well. Please read it.

We’re rape culture

I’ve been scared to walk on a darkly lit road maybe a handful of times in my life.

Every woman I know has to walk with full awareness of her surroundings, every single day all day long.

And this is considered “common sense”.

We’re violent.

Rape culture is not an isolated phenomenon

Violence is not just physical, but emotional and social and structural.

Right from the beginning, there have always been inequalities, and those with more, be it money, rights or power, always took away from those who had less.

There always has been subjugation

And war

Our treatment of women could be seen in the context of the overall violence that is human culture.

“Rape culture” is a (big) chapter in the story.

The threat of sexual violence is not limited to women. It’s anyone anytime anywhere who’s weaker. Physically, socially, structurally.

Ask any transgender person In India – or a gay man, strong, physically, but vulnerable, socially [TW: Rape].

Ask any young child, boy or girl , in a warzone.

Ask old people, young people, orphans, incarcerated people.

And sexual violence is not the only kind.

There’s the all pervasive physical violence of growing up in communities where children beating each other up is just boys being boys.

There’s the daily threat of violence hanging over beggars, the invalid, and even the strong pick-axe wielding laborer.

Violence from the police. From pay-masters, from care-takers, from local goons, mafia and just driver-bys who don’t like the sight of them.

There’s economic violence, of course, all about policies and embargoes and things too complex for me.

There’s structural violence, in healthcare, where a doctor is the boss. Where a nurse is hired for hard labor, not her brains. Where “you just do what I say, or go somewhere else” is the norm, even when it’s my health, my life, that’s being discussed.

In government’s policies which favor some kind of behavior over others. Which tell you that you’re being watched all the time, and that saying or doing something that displeases the powers that be will be costly.

Too depressing, this is. Let’s smile a bit.

http://www.reddit.com/user/popisju

Aren’t baby elephants the best? For a change, we’re protecting them now.

Things are better than ever in history.

Sort of.

Relative numbers- the rate, or ratio of a thing, as opposed to absolute number.

By relative numbers, there are far fewer deaths from wars. Far fewer violent crimes, and far fewer deaths from poverty.

By relative numbers, far fewer women are at risk of violence perpetrated by their employers.

By relative numbers, far fewer mothers die in childbirth.

There’s also outrage.

People are talking about rape. When someone says something ghastly, like Indian ministers regularly do, people are shocked, they demand apologies.

Perceptions about violence has changed. A hundred years ago, a public hanging would have been gleefully attended by hundreds. Today, we can barely look at photographs of these events. In fact, there aren’t all that many public hangings anymore.

People are asking for safe cities.

There are Gay Pride marches.

And Slutwalks.

We’re aghast when we hear about violence. Not the social media kind of aghast, but actually. It hurts us to see others’ hurt.

This is a luxury not afforded by most people who have lived before us.

Why talk about the whole story?

Definitely not to discredit the existence or enormity of rape culture.

But to underscore that it’s violence as human choice we are fighting, not an isolated behavior. And that admitting that rape culture is real is an important step in addressing the violence culture.

And to remember that some of the best ways to fight rape culture, as with any form of violence, may have no direct link to it. Like fighting for sanitation, or universal health care, income inequality education of women, child marriage, female infanticide, diversity at workplace, or organizing against governmental corruption.

But

What do you believe?

That we are improving as a species, or that we’re worsening?

We can’t objectively know, you see, we can only argue, believe and act.

Mostly act, I hope. Because that’s what fits my belief system.

That’s what helps me make sense of my world and gives me (one) reason.

Our basic nature

“It is one of my fundamental beliefs that not only do we inherently posses the potential for compassion but I believe  that the basic or underlying nature of human beings is gentleness. —[Tenzin Gyatso the 14th Dalai Lama]

For most of my life, I have held that man is essentially a base, angry, hurtful animal. Gentleness and kindness are acquired through civilization and practice, and if given a chance every person would do the thing that benefits them the most, even if it hurts others.

The online conversation in India has recently become rape-focused. Triggered by the Delhi gang rape, what was a tsunami of outrage is now a stream that is here to stay. Almost universal in the portrayal of rapists is the use of terminology that indicates that men who rape are reverting to their “real” nature. Forget what this says about men, what does it say about humans in general?

Yet, we do not have difficulty in believing this. This drives us to propose the harshest possible penalties on rapists, and insist that the basis for a rape-free society would be harsher punishments, and longer sentences. I’m even hearing suggestions that minors who commit sexual crimes should be treated as adults.

I would have discarded the Dalai Lama’s belief as religious wishful thinking if not for the evidence he presented. He asks why, if we are evil, does evil hurt?

If we are by nature evil, why does it hurt us so much? Why does good have physical as well as psychological benefits?

Not all “good” behavior has proven benefits, other than feeling good. But many do, and from violence to resentment, there is research to suggest that negative emotions and “bad” behavior can lead to physical effects.

It’s a good question, isn’t it?

Note: I’ve been re-reading “The art of happiness” a book that looks at Buddhist teachings about happiness in life from the point of view of a modern psychiatrist. The author, Howard Cutler is a  psychiatrist who follows His Holiness the Dalai Lama around for years, and catalogs the dialogues he had on topics ranging from romantic love to the nature of suffering. The book is very well written, easy to read and for any dysthymic/depressed person, a must-have. The quote above is from the book.

Petition to ban archaic/unscientific procedures during medical examination for sexual assault

Posting an email sent  by Sana [CEHAT]

Greetings from CEHAT!

As you must be certainly aware, the ‘Delhi Gang Rape Case’ has drawn some attention to the role of health systems in responding to sexual assault and rape. In this light, some of us – CEHAT, Human Rights Watch, and academics from JNU – have drafted a statement on behalf of medical professionals, highlighting some of these problems, and calling for reform in the manner in which sexual assault survivors are responded to by the health system. We hope that it will put pressure on the government to change the way in which they are approaching health responses to sexual violence in the country.

For more information on why the practices mentioned in the petition are
problematic, please refer to:

  1. FAQs on the role of health systems in responding to sexual assault
  2. WHO technical opinion

Please do have a look and endorse if you agree, and also circulate it to any other doctors, medical students or other health professionals you might be in touch with.

Please send in your endorsement in the following format:

Name:
Profession:
Designation:
Institution:
Contact:

to   cehatmumbai@gmail.com with the subject ‘PETITION’. The last date is 19th January.

Medical professionals demand the ban of archaic/unscientific procedures during medical examination for sexual assault

Move from evidence to care!

We, the undersigned medical professionals  , would like to voice our  strong protest at the continued use of the unscientific and inhuman “finger test”, the undue focus on hymenal status, and the overemphasis on genital injuries in cases of rape of women and girls in India. These procedures are still part of the current proformas being used in public hospitals in India and are contrary to the guidelines for medico-legal care of for victims of sexual violence issued by the WHO 2003.

When caring for victims of sexual violence, the overriding priority must always be the health and welfare of the patient.  The provision of medico-legal services thus assumes secondary importance to that of general health care services (i.e. the treatment of injuries, assessment and management of pregnancy and sexually transmitted infections).  Performing a forensic examination without addressing the primary health care needs of patients is negligent . As the WHO recommends, concern for the welfare of  the patient extends to ensuring that patients are able to maintain their dignity after an assault that will have caused them to feel humiliated and degraded.

Although the finger test and related procedures are outdated and have been officially removed, this has not translated into changes in the medico-legal practice . The evidence act also has been amended and clearly states that survivor’s character/past sexual history is not be commented upon.[1] Many doctors, police officials, defense lawyers, and judges use findings about the “laxity” of the vagina, the “elasticity” of the hymen, or “old tears” in the hymen to wrongly conclude that a girl or woman is “habituated to sex This practice should be banned with immediate effect, and all questions that allow such findings to be recorded should be removed from all medical protocols for the examination of victims of rape and sexual assault.

The finger test is legally irrelevant , as the Supreme Court  ruling in 2003 has ruled that finger test results cannot be used against a rape survivor, and that a survivor’s past sexual history is immaterial to the issue of consent at trial .

The finger test and comments on old tear of the hymen have no forensic value , as it predicated on the assumption that an unbroken hymen is evidence that no rape took place. Actually, the hymen is a flexible membrane that only partly covers the vaginal opening. Conversely, a hymen  may have an “old tear” for many reasons unrelated to sex, so examining it provides no evidence for drawing conclusions about “habituation to sexual intercourse”. In fact, only one-third survivors may report any injury. In  any case, whether or not a woman has had any previous sexual experience has no relevance to the issue of content.

The finger test is inhuman and degrading, itself amounts to  sexual assault.  Most doctors and hospitals tend to seek blanket consent for the medical examination. Therefore rape survivors have little information about the actual medical procedure involved.

In addition to the banning of the finger test, there is also an urgent need for a collective proscription on comments on the hymenal status and position as well as on the degree of tears and the overemphasis on evidence collection at the cost of provision of care.  Many countries have operationalised the WHO guidelines of 2003 and made changes in their practice. In India, the results of these methods are routinely used by defense counsel and relied upon by judges in rape trials to unscientifically determine a rape survivor as “habituated to sexual intercourse”.

We also reiterate the dual role that medical professionals should play in their response to sexual assault as health care providers and those who assist in medical evidence collection.  As the WHO guidelines on medico-legal care of victims of sexual assault says, the therapeutic care for rape survivors should be the “overriding” priority when doctors respond. We are concerned that many hospitals and doctors in India do not provide adequate therapeutic care, including access to emergency contraceptives, prophylactic medications, counselling, and information about HIV and other sexually transmittable diseases lack of such care can lead to aggravated health consequences for the survivor
This practice cannot be eradicated until the central government intervenes  and issues a uniform gender sensitive protocol that is made applicable across India, with adequate resources to train and monitor the use of this protocol.

We demand that the Indian Ministry of Home Affairs together with the  Indian Ministry of Health and Family Welfare should:

  1. Ban the finger test and all its variants from all forensic examinations of female survivors, as this are unscientific, inhuman, and degrading practice
    1. Develop and institute in consultation with Indian women’s, children’s, and health rights advocates, doctors, and lawyers, a protocol for the therapeutic treatment and gender-sensitive examination of survivors of sexual violence  , such as those has already used in Mumbai public hospitals and endorsed by several health professionals.
    2. The protocol must comply with the standards and ethics issued by the World Health Organization, including the right to provide or refuse informed consent for medical treatment and examination.
    3. The protocol should emphasis on the need to seek the history of the incident in order to collect only relevant medical evidence  ,  correlate findings with the nature of sexual assault reported, record delay in reporting, and note other activities such as bathing, douching, urinating after the sexual assault that result in loss of body evidence.
    4. The protocol should exclude the following information: size of the vaginal introitus/hymenal opening/number of fingers admitted by the opening; comments on old tears of the hymen; comment on habituation to sexual intercourse; irrelevant obstetric history (such as history of past abortions); findings on women’s built, nutrition, weight and height
    5. The protocol should include clear directions for provision of Emergency Contraception, HIV/STI prophylaxis, treatment for immediate injuries, psycho social support to the survivors and her family, and follow up care  .
  2. Devise special guidelines for the examination of child survivors  of sexual abuse to minimize invasive procedures.  Ensure that any test is only carried out with the fully informed consent of the child, to the extent that is possible, and the informed consent of the child’s parent or guardian, where appropriate.
  3. Instruct doctors not to comment on whether they believe any girl or woman is “habituated to sexual intercourse”.
  4. Instruct all senior police officials to ensure that police requisition letters for forensic examinations do not ask doctors to comment  on whether a rape survivor is “habituated to sexual intercourse .” and/or whether rape has taken place or not
  5. Communicate to trial and appellate court judges that finger test  results and medical opinions about whether a survivor is “habituated to sexual intercourse” are unscientific, degrading, and legally irrelevant, and should not be presented in court proceedings related to sexual offences.
  6. Update all medical jurisprudence textbooks to specifically  exclude the finger test and its variants. Ban the use of medical textbooks that rely on the “finger test” and its variants by defense counsel to badger and humiliate the survivors of rape, sexual assault and child sexual  abuse.  Currently, forensic textbooks prescribe the finger tests and provide details on types of hymen. In their advice on how doctors should make observations in cases of alleged rape, there is a regrettable continuing overemphasis on injuries. Some textbooks teach students that “a health woman cannot be raped’, ‘working class women are muscular and so can offer resistance”, ‘if sexual intercourse is forced, then injuries must be present’, etc.
  7. Introduce a mandatory special curriculum on the dignified  treatment and examination of sexual assault survivors as part of medical education.

Not silence but Verse: Call for poetry against Violence

It’s violence against women (VAW) awareness month, and Prajnya  is calling you to submit poetry

Send us original, powerful, evocative poems in English, Hindi or Tamil
(Haikus or Tankas only!)
on the theme
‘No Violence, No Silence’

Last date for submissions: 10 November 2012

Email us: prajnya.16days@gmail.com

(Download the .pdf version of the call here.)

 

So, all you poets, write!

Tag at source

Back in the day when pirating music was a big thing, I too had an impressive 40 GB collection. When I say “back in the day” I am talking about the time when internet was all dial-up and the fastest broadband available was 128kbps.

40GB of mp3s is more than you can listen to in a lifetime, and knowing this did not stop me from acquiring it. Not all these were downloaded from the net, I, personally preferred ripping cds that friends and relatives and neighbours had. Now, as you can imagine, organizing these MP3s was a bitch. The regular mp3-pirate was expected to know what tools to use and how to keep the library organized. So I used tools like music brain picard, tagmp3, mediamonky and (my favorite) foobar2000. These lovely tools, used correctly would ensure that my mp3s were tagged, categorized and organized in the folder structure of our choice.

But all these tools were useless if I did not follow the golden rule: Tag at source.

Once there were a few GBs of untagged stuff on my hard drive, it was next to impossible to make sense of it.

Every pirate knew this, if you dont tag at source, you are going to end up with useless music.

Sort at source – this is a golden rule for life.

Impossible Choices

“Do the right thing” you were taught as a child, and strive to do so as an adult. But what they didn’t teach you as a child is about impossible choices. Situations that not only have no right choice, but just by their existence change everything.

Life loves playing the “heads I win, tails you lose” game with us.

Next time you are faced with a choice which will mess you up irrespective of whichever way you chose, remember this; impossible choices are life’s way of telling you you are not in control.

What do you do when faced with one of these choices? No idea, so far, i’ve been fucked over by every one of these. I guess you pick up the pieces, learn to be happy where you are and be prepared for the next time.

Forces

“What happens when an irresistible force meets an immovable object?”

A young priest fresh out of seminary once asked me, when he learned that I was a fan of philosophy and other arcane things. I remember the delight on his face, watching me struggle to come up with an answer. He did not give me one. This is a famous paradox also known as the omnipotence paradox.

Much later, I learned that the correct answer is- such a meeting is not possible, because, by definition, if there is an irresistible force, there cannot be an immovable object. This is a rule in logic.

Life doesn’t give a rats ass about the above rule.

You will face things that simply should not exist, but do. Good things and bad. Forces, events, emotions, people that cannot possibly be, but are. Life’s like that.

Non-Negotiable

All of us have non-negotiables. 11 years ago, fresh out of home, when I went to college, my religious beliefs were non-negotiable.

“There is one God eternally existent in three persons, the Bible is His word and The Brethren ( my church) understand it best”

In a year, the last part eroded away. Then the others did too. After a decade , a bare-bones, qualified version of the original statement of faith persists.

The evidence based practice of modern scientific medicine was the non-negotiable then. No way I was going to be a quack.

Then I started practicing medicine and realized that there was much my training was completely useless for.

Some time along the way, I also picked up a love for the free market economic system. And then, that changed too.

Today, some of my old non-negotiables are back, most are new.

Honesty is not always the best policy, but family always comes first. The definition of family has changed, though.

Here’s what I’m saying: If you are doing it right, you will chip away, brutally, at all the things you were taught or believe are the most important things in your life, and then constantly refine the remaining list.

Most of your non-negotiables are negotiable.

The glorious battle

J oswald chambers zen pencil we were made for the valley
Adapted from the lovely zen pencils cartoon linked below.

Remember that part in the new karate kid movie when Jackie Chan makes Will Smith’s son put on and take off his jacket again and again and again and in the end  it all makes sense because he was teaching him the greater lessons about kung fu? And how in the end he uses this knowledge to win that big amazing glorious event?

Here’s the thing; most of us- we’ll never have that final glorious battle.

We just get to take the jacket off, put it on again, and agin and again till we “get” it. Because character and life and all that grown up stuff is not about how you do in the last glorious battle, it’s about how you do now, today, tomorrow and the day after that, even when there is no glorious battle right at the end.

Inspired by this brilliant-as-ever Zen Pencils comic:Made for the valley