We can improve India's healthcare, by fulfilling the specific requirements in logistics, access, staff and funding of three distinct subsystems in healthcare: 1) preventive & wellness, 2) hospital and 3) rare disease & emergency.
Last month we fundraised for a 9-year old boy named Suman who was suffering from Japanese encephalitis, and whose father was unable to afford treatment. Suman's situation and of several others (visit Milaap) revealed the glaring flaws in the Indian healthcare system. What kind of independence is it, when the masses can't afford a treatment that the family and friends of the more affluent, powerful and connected can?
We have to stop looking at Healthcare as one large system, and view it as a collection of several subsystems:
Preventive & wellness healthcare needs to be accessible in close proximity to everyone. The costs of this care are low, and closely linked to nutrition and lifestyle, and the costs can be borne by people themselves. There is a huge scope for the private sector in this area and the government should promote private enterprise in the preventive & wellness healthcare sector. Special emphasis should be given to women's healthcare needs, as the prenatal womb environment can have a significant impact on the future health of children.
Hospital healthcare needs doctors, nurses and advanced equipment, and it serves at one time a smaller number of people in need for medical care. The costs are high, but the middle class and richer families can pay for the treatment, while the poor should be assisted in part by the government. There is a scope for both private and public institutions in hospital care. Managing and improving hospital care has been the emphasis of governments, but without proper preventive & wellness and rare disease & emergency healthcare systems, hospital healthcare is overloaded and inefficient.
Rare disease & emergency healthcare needs specialised and sophisticated care. The number of people served by the system is significantly lower, and the costs of care are very high, especially when they require a rapid response (air ambulance) or rare surgery (transplants). The cost of this care can be borne by the government for all cases. The government should institute a military style health service (MediCorps?) that caters to special needs of rare and emergency healthcare.
By classifying healthcare in preventive & wellness, hospital and rare disease & emergency, and by having special logistics and funding arrangements for each, we can improve the healthcare system. When preventive & wellness care is good, the need for hospital care is lower, and this saves costs for everyone. Similarly, the treatment of rare disease & emergency conditions should work like a national insurance scheme where people by making small investments, insure themselves to get military grade well-coordinated health service.
Any more suggestions, especially from people associated with healthcare, are most welcome.
I do not like to act like a seer, as we often get caught up in bubbles, believing the immediate past trends will carry forward in the future. The number of uncertainties in the world are too many, to predict anything with either precision or accuracy. Anyway, if a pattern emerges that lasts a decade, you need to give it some due emphasis.
Many say the rising inequality is a problem. I agree it is, but I would say the rising inequality, in the long run, is a greater problem for the rich than the poor because it is the rich who will be the greatest losers. The financial crisis of 2008 was an unprecedented event, but the events that followed were more unprecedented. Those who were the direct actors in the creation of the storm, the finance industry, has withered the storm and even taken huge bonuses and public bailouts home, while those who were at the receiving end still struggle to get over the damaging consequences of the great recession. I will not argue the merits of either side but will provide a clinical analysis of what such an uneven growth implies - where the rich got richer and the poor struggled. We can see what it implies all around us, the Occupy Wall Street, the 2014 Ferguson Protest, all of it are fuelled by a perceived sense of injustice, that few wealthy men (mostly) have an unnaturally large level of control on people's lives. I have heard the lobbyists of the Wall Street and the City argue how such perceptions are misjudged. However, you can't change perceptions by giving fat bonuses to bosses! Even if for a moment it is agreed that the agitated public today is merely a victim of misperception, the misperception is too strong.
Maybe there exists a belief in the power circles of the Western world that such sense of injustice will calm down once some fraction of the large wealth of rich will trickle down. Some believe that we should let the 'hard working and smart' rich get very rich and then some parts of their income will eventually go to feed the 'lousy' poor. What explains this patience of the disproportionately rich with the current agitations?
In the past few decades, the social capital in western democracies has eroded. Prof. Robert Putnam in his book Bowling Alone presents this case, where he argues how the famed civic values of America are under threat. The union membership has declined precipitously in the USA in the past decades. I have my own analysis of why this is happening. I agree with Prof. Noam Chomsky that today media in the developed world closely resembles an oligopoly or even a cabal owned by a few well-connected firms. Although a paper by Mullainathan and Shleifer "The Market for News" at AER (2005), suggests the news media is driven primarily by the slant of its customers, and not producers, however, there also exists evidence how media can impact people's perceptions (see Chiang, Chun-Fang, and Brian Knight. "Media bias and influence: Evidence from newspaper endorsements." The Review of Economic Studies 78.3 (2011): 795-820.). A paper by Maja Adena et al. (see Adena, Maja, et al. "Radio and the rise of Nazis in pre-war Germany." Available at SSRN 2242446 (2013).) showed the impact of media on the rise of Nazis in Germany which provide us a chilling reminder of the power media can wield in impacting our perceptions (remember Mein Kampf?). There are sections of media that constantly attempt to 'entertain' us, or rather distract us, and attempt to mold our perceptions. The 'talking points' on Iraq War where the Bush administration had a preplanned approach on how to influence public perception in support of the war is a good and a relatively recent reminder of that. So is the media campaign to present climate change as a 'green agenda.' It isn't too outlandish to believe that a similar PR exercise is underway to alter public perceptions about inequality that how fat paychecks (even in a recession) to few is 'good' for all or at least completely normal. Such an attempt to distract public opinion, and make them feel restive but silent, has a direct impact on people's ability to come together and take a stand. Thus the elite section of society believes the general public would soon get over their anger and settle for the status quo.
However, there are new trends, the trend of social media, which is disrupting the current media oligopoly. Just recently Disney announced the acquisition of a major YouTube based production company, signaling the rising importance of internet media in the industry. As the media industry disrupts so will the zeitgeist, which leads us to an unknown territory. There is a reason to believe that as new media takes center stage, it will directly improve social capital in democracies, and spurt new civic engagement and make democracy more participative. However social capital can go the other way if in case people are unable to build cross-constituency social capital in time and amidst a zeitgeist of fear they barter freedom for security or violence. In such a setting such new media can promote radical ideas that take society towards the far left or right, directly threatening the democratic ideals of western nations. One should remember that the rise of Hitler too happened in desperate times right after the great depression of 1929-30 and was helped by the negative social capital of homogenous groups. We have also seen the rise of radical right parties in the UK in recent times. Similar is the rise of anarchist and communist movements which have become more vocal and active in the past few years which distrusts the electoral process. There is an increasing antipathy of people towards the Westminster or White House which are considered not edifices of democracy anymore but rather mouthpieces of the City and the Wall Street.
If the first scenario of positive, participatory democracy plays out, there will be redistribution, the public will benefit, and the size of the rich will be cut down and constrained. If the second scenario of fear and retribution plays out, while the public may be ecstatic at the beginning, however soon hysteria will pave the way for oppression. New power cabals will get created, and most certainly the old will be dismantled. The status quo is unsustainable in a long run because it has been here for a long time and the zeitgeist demands change, and it is important that the existing power elite wakes up to this reality. While change is inevitable, the direction is not, but the greater the resistance from the elite to regulate itself, the sharper will be the response from the public. So, it is only prudent that the elite understands this, and as a precaution repositions itself, by being open to redistribution through higher taxes. It must take the lead from figures like Warren Buffet and Bill Gates to champion fair redistribution, and not act as gatekeepers of wealth. Leaders like Obama or Cameroon have no room for future error because they need to push an agenda which does not put the liberal democratic ideals of their nations under threat. They need to reclaim their nations from plutocracy and save their nation from the possible shift towards something worse.
Leaders need to give their country back to their people.
Brief: Development needs just a little push. The problems we need to look at aren’t huge, ambitious, or those that take an entire lifetime solving. Solving these problems won’t bring us fame, or awards or admiration. They may not even change lives drastically. But if some of us can make it a habit, to engage in community building we will be like silent warriors. We meet one of these silent warriors, Dr. Samadhan Patil.
At the stroke of midnight in 1947, when India made its tryst with destiny, I often wonder what was in Nehru’s mind. There is an India that is racing ahead on its way to Mars. There is another India where a poor farmer in Vidarbha can’t even make his way back home; he dies on his way, dehydrated and starved in his journey of 35 kms, just because he doesn’t have a penny to afford transport. Such a stark difference!
Is it even possible for some of us to live at the cusp of both realities? So, let’s meet Dr. Samadhan Patil, a scientist at the London Centre of Nanotechnology, a premier research institute in nanotechnology and a joint venture between London’s two research giants UCL and Imperial College London. An alumni of India’s prestigious Indian Institute of Technology Bombay, for the last 10 years he has lived in Lisbon and London, away from his small ancestral village, Ladli, in the Indian province of Maharashtra. Yet the distance hasn’t stopped him from being connected to his village.
Getting Down the Drain
Dr. Patil’s village isn’t very prosperous. When he was in primary school, he recollects there were only three teachers, and each teacher taught two classes simultaneously in the same room, as the school was made of just two rooms. In regions around Ladli, farmers committing suicide out of inability to pay debt is common. In spite of the limited resources, he says his village has supported him throughout his journey, in the good and the bad times, and it is where he feels relaxed and at ease. This is what drives him constantly, for the last twenty years and more, to be involved in big and small ways in developmental work in his village. His story tells us that change doesn’t need support of an institution.
Just a few years back, during a short visit home, he got down in the village’s drains to clean them up. He was fed up with all the dirt clogging the drains! Though he started alone with a friend, he was soon joined by small children, who were more than glad to get their hands dirty. Slowly more than 20 others joined him, and it ended up becoming a massive clean-up drive in his village of 1000 people. Today, thanks to greater awareness among villagers for cleanliness, and some help from the government, the village is much cleaner than it used to be. His little effort just got the ball rolling.
The Problem of Motivation
Some changes are harder to bring than others. Another time, Dr. Patil took the initiative of tree plantation. He says while once entire regions used to be covered with trees, he was very alarmed to see how rapidly the canopy had dwindled from the region. This time, as he was in London, he instead persuaded his friends in the village to take up tree plantation. After some initial hesitation, they were soon huddled together and he was hoping to see great enthusiasm. However, unlike cleanliness where results can be seen soon, tree plantation needs a much more farsighted commitment. To motivate villagers, he even volunteered to award around £50–100 from his own pocket to every villager who was successful in saving a sapling from dying for two years. Yet, only a few trees got saved. However, the lukewarm outcome hasn’t disappointed him. He says, “We as individuals might be motivated, but when working in groups, the magnitude of certain problems makes us feel paralysed. We have the means to bring about change but lack motivation.” This reminds me of Professor Teresa Amabile, a leading researcher at Harvard who has done some astonishing longitudinal studies documenting people’s work lives. She has something similar to say on how it is not big achievements but small wins that motivate people and push them to be creative. She calls it ‘The Progress Principle’
Dr. Patil’s successes and failures maybe point us towards a simple way towards social motivation- We need to start small, with small problems that can be tackled and won.
We often hear about big bang achievements of social workers, yet how many of us have the time and resources to leave our careers to start an NGO or to make a disruptive social innovation? But should this demotivate us from being agents of change? Maybe it is high time we stopped waiting to make the big splash. Can’t we be silent warriors?Dr. Samadhan makes use of his strong social networks in his village to persuade locals. Back in 2010, Dr. Samadhan’s persistence helped his village elect a leader by consensus saving the village from political factionalisation. While democracy is good and it is nice that his village has a colourful local democracy, too much competition in a democracy can often lead to polarisation. Unfortunately, sometimes such polarisation divides instead of unites people. Dr. Samadhan insists that what villages need first is unity. For the last few months, Dr. Samadhan has been spearheading a local water conservation project. He wants a small dam to be built from the local village funds. He says, the village has the money, however this money would be given to contractors for infrastructure projects, and he is not confident if all the money will be used effectively. He wants the village government to take on the task of building a dam all by itself. He says the dam isn’t too complicated to build, and he is willing to lend his engineering expertise. He says this project, while on one hand give good sustainable jobs to Ladli’s youngsters, will also create a sense of community and lift up village’s esteem and spirit.
Hope and Despair
In our conversation, we keep coming back to the same idea: the need for spirit and motivation. His words here remind me of Nobel Laureate Professor Amartya Sen. In a lecture last year at LSE, he talked of the role played by Rabindranath Tagore, the legendary Bengali polymath and Nobel winner, in lifting the spirit of Asian nations in their fight for independence. Prof. Sen reminded us how many Asians in the late 19th and early 20thcentury used to feel humiliated by the vast disparities between them and Europeans. Europeans appeared to be like a superior civilisation that dominated the world. Was competing against them even worth the effort? Then Japan, as an exception in Asia, rapidly modernised itself, and Tagore was one of the first writers to write about this miracle. Prof. Sen writes “…he (Tagore) saw the need to build the self-confidence of a defeated and humiliated people, of people left behind by developments elsewhere, as was the case in Japan before its emergence during the nineteenth century.” Soon this story of Japan’s nation building was told and heard by many in Asia, and it fuelled a new spirit of nationalism.
An Army of Silent Warriors
The spirit people in our villages need isn’t to fight an aggressive invader. Dr. Patil is hopeful that development in India, and for that matter any nation, needs just a little push from people who are willing to give some of their passion and some of their time to solve problems around them. The problems we need to look at are not huge, ambitious, or those that take an entire lifetime to solve. Solving these problems won’t bring us fame, awards or admiration. They may not even change lives drastically. But then, if some of us can make it a habit to engage in community building in places that have been forgotten, which just need a little push, we will be like silent warriors. Our march towards development is long. If each one of us can commit to a village of a thousand people, then to cover the 7 billion of us we will need an army of 7 million silent warriors in the world!
Where do we find these 7 million warriors? Civic Engagement has been a tricky topic, as while some regions seem to have a lot of it, some others remain paralysed. This is very well described by Prof. Robert Putnam’s authoritative work on Civic Traditions. It is a vicious cycle: despair breeds distrust, which creates more despair breeding further distrust, such that some communities remain in a state of seeming paralysis. However there must be some self-starters in every place like Dr. Patil in Ladli, who keep engaging in some good work just out of habit of volunteerism. Such leaders (although with just a few followers!) have a vast bank of experiences and best practices they are willing to share. If we could bring volunteers like Dr. Patil together, and create a digital community where the best practices are shared, can’t we make a dent and create some impact? Possibly if we could make grassroots related communication (which usually gets eclipsed by political, sports, business or celebrity related news) more effective, we can reach a tipping point where more and more people are motivated to take up small community development projects, and which in return could push the locals to find a renewed spirit and to take development in their own hands.
An army of 7 million silent warriors for 7 billion of us… is that a lot in the cyber age? I leave the question to the august community.
Connecting the Grassroots
Let’s do a reality check. In villages like Ladli, Google may still be a novelty. Internet, let’s accept it, needs literacy, and the poorest of the world aren’t still so literate. Even if the local community leaders are literate, internet access is still either inconvenient or too slow to help us easily reach a critical mass of participation. So here is an idea. There are over 6 billion mobile phones today in the world, covering 87% of human population. While mobile penetration is still low at around 21.8 per 100 in some African countries like Ethiopia, larger developing countries like India (90.47) and China (89.2) are close to fully covered. We may have heard of astonishing innovation around mobile phones like the M-Pesa in Kenya. However it is time that the grassroots activists got connected. We need the mobile phone (not smartphone) to be the tool for social communication.
In developing countries, increasingly the mobile phone is being used as a tool for political participation, and its usage has been widely studied during Arab Spring. Startups like Text-to-Change are using the mobile phone to broadcast useful information to people in developing countries. While different innovations of mobiles have been tried and tested, a coordinated effort to channelize the voices coming from the world’s forgotten backyards, and to create an effective sharing platform is still missing. While Facebook connects today more than 1 billion people, the rest of the 6 billion are still not connected, and usually live in the remotest regions. We need a social network like Facebook that is so primal that it works via text messages, so that local community volunteers can stay connected and engage in a global conversation, highlighting their causes, supporting other’s and most importantly sharing good ideas. There are simple hacks for it that can be easily implemented. For example, Twitter provides tweeting via SMS, and if a convention of hashtags can be pushed, the hashtag can help collate massive development related tweets arising from forgotten hinterlands of the world, where cyber space still hasn’t penetrated. In fact, community volunteers do not even need to register on twitter. They can simply SMS their messages to a national number, which can then tweet these messages on twitter. The idea is to make communication as seamless and less complicated as possible, so that more and more community leaders can join, and we can start a serious and mainstream conversation on grassroots development.
Originally published at www.gsnetwork.org