Healthcare Legislation is Relevant to the Whole World

The decision of the US Supreme Court to uphold Affordable Healthcare Legislation is of great interest to the whole world, not merely to the US. Visit

http://www.washingtonpost.com/politics/supreme-court-to-rule-thursday-on-health-care-law/2012/06/28/gJQAarRm8V_story.html

Insurance is a good idea for evening out the burden of unpredictable health costs. Life strikes some people very hard and insurance, in principle, can spread the burden over the whole adult population and make life bearable for the poor souls who get hit by diseases that necessitate major expenses. But how does one ensure that the health insurance industry is properly regulated? How does one prevent excesses in healthcare costs being imposed by hospitals and doctors? Can one do all this without excessive bureaucracy?

I hope that leading university departments of public health around the world give these questions adequate attention. Such departments in the US will no doubt have their primary focus on the US context. However, some researchers should suggest answers to these questions at a more global level; they should, at the least, stimulate a worldwide debate on this topic. It is not clear if a UN body such as the WHO can do anything about these questions.  Let us ask http://twitter.com/#!/who

People in many countries live on per capita GDPs at the level of a small fraction of the US per capita GDP. Giving them satisfactory healthcare is not easy. Neither the individual nor the state can bear the huge costs of modern healthcare. Researchers have to investigate this immense challenge and provide some answers. Ultimately we can do only what we can do! No more! We have to apply our mind to the issue of what we can do if we come up with the best possible ideas.

Srinivasan Ramani

R. E. Bedford, Professor Emeritus, IIT Bombay

Professor Bedford made a big impact on my life, because he had those qualities that great teachers have. He was a professor and a gentleman! From him I learnt that a teacher is one who does not merely impart some knowledge and skills; a real teacher goes beyond that, serving as a role model inspiring his students.

I had specialized in heavy current engineering for my university degree in electrical engineering. Over the next fifty years, a lot of work on alternative sources of energy would be done by people with such a background; it is an exciting area for research.

However, when I applied for admission as an M Tech student at IIT Bombay, my heart was in computers. I turned up for the admission test, but a stern official would not let me take the paper meant for the candidates applying for work in electronics. So, I took the one meant for heavy current engineers and managed to get to the selection committee for an interview. Prof Bedford was, I think, the Chairman of the Committee. He greeted me with his characteristic good humour, saying "We hear that you don't want to work with us!" I described the ruling the official had given. "So, what do you want us to do?" he asked. I said that I would like to be interviewed in the area of interest to the Committee. Subsequently, if they thought I merited some consideration, they could perhaps pass me on to the other Committee with a recommendation. Luckily, I passed the hurdle of the first interview. Prof Bedford personally took me to the other Committee and said something like "This chap doesn't want to work with us! See if you want him to work with you". Despite the light-hearted remark, he had somehow conveyed that I deserved a second interview in his opinion.

Prof Isaac and Prof Pradhan were in this other Committee. After another interview, they selected me. I had come out of old-fashioned educational institutions where rigid hierarchy prevailed. That an IIT could be flexible enough to admit for an M Tech in electronics a bloke who had taken only one paper in that subject was amazing to me. Inter-disciplinary barriers had been worse than caste barriers, but they did not exist in the mind of IIT professors; at least in the minds of some of them! I suddenly saw how IIT's differed from the institutions left over from the Jurassic period!

Bedford and Isaac belonged to the new breed of academics, who treated students as humans and interpreted rules without forcing narrow minded interpretations into them. This modern approach to academic decision-making went a lot further. Later, I graduated from the IIT Bombay and went on to work at a reputed research institute pioneering in the computer field. What about working for a PhD? IITs had no rules to enable even researchers working in the same city to enrol for a PhD. Should institutional barriers be water tight and exclude collaboration and sharing of ideas beyond the walls of the institution? Bedford and Isaac worked with other like-minded professors to get the senate to approve "external registration". I became a student at IITB again and completed my PhD work under the joint supervision of Prof R Narasimhan and Prof Isaac.

I have served as a professor later in life, and hope that I have given my students in some small measure the same support and encouragement I had received from Prof Bedford. His passing away on Monday, June 25, was a major blow to all of us whose lives had been influenced by him.

Srinivasan Ramani
June 28, 2012

More on the bore-well that killed a baby girl in Manesar

India Today has commented on the case I had discussed on this blog on June 24, 2012, and has also commented on the need to be prepared to meet mass-scale disasters such as earth-quakes. Visit

http://indiatoday.intoday.in/story/draw-the-right-lessons-from-mahi-tragic-death/1/202448.html

This item also reports on the role of Sohrab Khan, a local well-digger, who eventually got her body out of the well. This does not in any way detract from the credit that should go to the army personnel who worked night and day to dig an 80 foot parallel well to enable access to the bore-well.

The question about preparedness to cope with mass disasters is this: with whom does the responsibility lie? I would vote for the Chief Secretary of the State and the Secretary to Govt who supervises the fire department. They are well-educated, trained government officers who ought to be trained in disaster-management as well. Every mass disaster should be reviewed by a judicial commission, and if unpreparedness or incompetence is established, the officers concerned should have their jobs terminated.

A soft state is one which does not assign clear responsibilities and does not punish negligence and incompetence.

Srinivasan Ramani

Sakunthala did not know what they did to her

Sakunthala (name changed) works as a housemaid, cleaning vessels and sweeping floors in three or four homes. She has a husband who drinks frequently and beats her, and a teen age daughter. She had to go to a big hospital recently for pain in the abdomen. They told her that an operation was necessary. From what she told us, we could guess that there was going to be the removal of a fibroid. We visited her in the hospital a few days after the operation and were happy to hear that she was recovering well. We asked her if the doctors had removed her uterus, as they often do when they remove fibroids in women nearing the end of the child-bearing age. She did not know, and was surprised to her that such things were done. Her daughter was near her, and we asked the girl if she could ask the ward nurse to give her the case sheet so we could find out. Then we realized with a jolt that we were asking for things beyond patients’ rights in a hospital that provided free treatment to those not able to pay for it.

The staff nurse came charging down the aisle and told us that case sheets are not for patients to read! We were sufficiently humble, and said that all we wanted to know was if there had been the total removal of the uterus, and if there had been a test for any possible cancer. The nurse did not know, but had a quick method of finding out. She asked the daughter if “they” had given a plastic bag to be carried to a building which she pointed out, to be deposited there. This had not happened. The nurse declared that if there had been any need for testing for cancer they would surely have given a plastic bag to the patient’s relatives to be carried to the other building. Removal of the uterus? Yes, of course! She was sure that would have been done.

We were disturbed by this during the following days. Why did they treat patients the way veterinary doctors treat animals? No need to talk to them and tell them about what was being done to them? If we had seen the case sheet or other information sheet meant for the patient’s information, would it have been in a form readable by the patient? Would it have been in the local language Sakunthala could read, or in English which she cannot read, or in squiggles?

Ours is a city in which the street names cannot be read by a high percentage of the people because the local government considers it politically unwise to display street names in any language other than the state’s official language. But when it comes to giving information to the patient? If you can’t read English and do not recognize medical abbreviations, you are treated like the veterinary doctor’s patients!

I guess that we ought to be happy that India gives some form of medical care to every one, whether they can pay for it or not, irrespective of what the care is worth! There are well developed economies in the world that do not wish to provide universal health care. Our citizens are better off, in a manner of speaking! But can we improve our practices? Can hospitals treat patients not as a burden but as their customers? After all, it is the people’s money that the hospital runs on, not on anyone’s inheritance! Shouldn’t hospitals have a patient’s charter and enforce it?

S. Ramani

National Disasters

India has been patiently waiting for 80-odd hours for news of the 5-year old Mahi who fell into a bore-well which had been dug without permission from any authority overseeing building codes. Visit

http://indiatoday.intoday.in/video/gurgaon-rescuers-reach-5-year-old-girl-mahi-who-fell-into-a-borewell-after-80-hours/1/202142.html

Lodged at the bottom of a 70 foot well, her life has been endangered by lack of oxygen. There have been spirited debates on television about the lack of coordination in the rescue effort. I hope that the child will come out alive out of this horrible experience, thanks to the brave men of the Indian army who have risked their own lives in the effort to rescue her.

What does the nation have to learn from this “accident”? TV anchors have yelled at the authorities who had turned a blind eye to a bore-well being dug in close proximity to a residential building. The callous builders have left the well uncapped, knowing that it is a death-trap for children going near it. I think of the general disregard for the law in the construction industry. This is not isolated as road accidents claim tens of thousands of lives every year due to disregard for traffic rules. Non-implementation of traffic rules is something India has accepted without any protest. Yesterday I travelled a hundred kilometers on a toll road after sunset and passed well over a hundred trucks. Very few had red lights on at the back. School buses regularly crush children while reversing, because the drivers are unfit to be trusted with any vehicle – none of them has any difficulty in buying a driver’s license.

Coming back to lax implementation of building codes – an astute commentator on TV said “If there is an earthquake in Delhi tomorrow, hundreds of thousands will die”. What agency can deal with ten thousand buildings collapsing at one stroke? How will the hospitals cope with the event? The situation looks bleak for many cities and towns in India. The majority of buildings have violated building codes one way or another. They are death-traps as surely as uncapped bore-wells are.

Corruption is not confined to the politicians and high level bureaucrat. It is rampant in every city administration. Mahi’s plight should wake up the nation to this peril. I hope it does.

I will conclude by referring to the Wikipedia which says that the word bureaucrat is one of the toughest words to spell. Tongue in cheek, it suggests using the abbreviation “crat”!

Focus on e-Content for Education, particularly in Indian Languages

1.   I will focus on one topic that is going to be very important for India over the next ten years and beyond.  

2.   I am talking about e-books or books in the digital form, particularly those in Indian languages. What is special about them, as compared to traditional books? The effort required to create the manuscript is the same in the two cases. But, there are two major differences:

a.   The cost of production is zero. Once the first copy is ready, it costs practically nothing to produce the later copies. Low cost tablets will be available widely, and every educational institution would be capable of providing WiFi access to the Web. Every tablet would be able to carry hundreds of e–books, if not thousands. 

b.   e-books in Indian languages are very few. The tools for putting manuscripts into e-book are not available. Standards have not been evolved for e-book formats.

3.   There are plenty of writers in various fields in India, and academics who can decide what books are most badly needed and are likely to be widely used. But, let us not under-estimate the significance of the technologists who need to show how we should face e-book revolution that is staring us in the face, and is going to have a greater impact on India than even the green revolution.

4.   Inexpensive computing devices are coming up rapidly – starting with tablets. There will be a whole variety of them, manufactured by various manufacturers. I am excited by the low-end book readers – I bought a Kindle Touch for about Rs 5,000, using an impressive e-ink display that allows me to change font size as needed to read under different conditions. It is small, very light, is quite rugged, and has a battery life of over a month!
 

5.   All I want to take from the tablet discussion is that there will be millions of them in students’ hands sooner or later. This will require content in Indian languages – thousands of e-books, with millions of copies needed in the case of each one of them. The content will cost a lot more than the tablets will.
     

6.   I believe that there are over 70,000 public libraries in India, over a hundred and fifty thousand high school libraries, and over 30,000 college libraries. For the moment, consider the cost of acquiring copies of ten thousand modern books for each of these libraries. This will cost Rs 25,000 Crores. Now consider that you may need copies of about 20 books a year for each of the millions of tablets Indian students will acquire. There has been a lot of discussion about making tablet hardware inexpensive, but none about producing e-content in Indian languages.

7.   We need lots of ideas to deal with problems like this. I will discuss just one. Imagine a project which encourages those who write useful, good quality books for use in libraries. Let this project select 100 such books in any of the languages of interest to India including English, and give national awards with a cash payment Rs 200,000 each to the selected writers. This will cost Rs 2 Crores per year. Those whose books are not selected for the award will retain the commercial interest to their creations and will be free to take them to any commercial publisher. The awardees, on the other hand, will be expected to transfer all rights to the Govt of India, except the copyright in its non-commercial form. This will ensure their name as the author, along with a short bio, to be retained in every copy to be distributed. I would propose that that these books be made free to download all over the world. Books in most Indian languages will be of significant value only in India, but those in English may be very attractive in many other countries. This will enhance the visibility and prestige of Indian authors.  What about those who prefer printed copies? The project can authorize any and every publisher to print and sell copies of the books.

8.   Let me come back to the technical issues in creating e-content. We need to sort them out before we plan any major content creation project. What are the essential requirements? How much flexibility should we give to implementers and e-book creators? How important is it that the lowest cost devices should be able to benefit from e-content produced Govt funds?

      S. Ramani