Being Mortal in India

A peaceful, painless death is one of life's greatest blessings.

Atul Gawande's latest book is born out of experiences with those who, for most part, did not have this blessing. It discusses the way in which medical technology and social norms tend to mislead, dictate or overrule the options available to those who are terminally ill.

The book also brought back deeply disturbing memories of my father's last days at a hospital in Kerala. Much like a patient described in the book, he to was shuttling between hospitals and diagnostic labs, with an irreversible nervous system failure. Towards the end it was appalling to see somebody who stayed away from hospitals "drugged into oblivion and tubed in most natural orifices as well as a few artificial ones".

Gawande, with his focus on the prevailing healthcare system in USA, misses on some of the more disturbing aspects of what the urban elderly face in India. The fact that my father retired from the central government service prolonged his suffering in more ways than one. The first question they asked you at hospitals was - "He is fully insured under CGHS, isn't he?".

A comprehensive health insurance package seems to have prompted private hospital docs to prescribe drugs, diagnostics and procedures that were completely unnecessary. Towards the end, all the family members had to give a signed undertaking to get him out of the ICU, back into the pay-wards.

The priorities of the elderly, and the terminally ill in India may be the same as those in other countries -- to avoid suffering, strengthening relationships with family and friends, being mentally aware, not being a burden on others,

The challenge is trying to ensure that these priorities take precedence over those of the doctors, the healthcare service providers, pharma & diagnostic companies, as well as 'loving' family and friends.


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LINKS

Homepage - http://atulgawande.com/book/being-mortal/

Gawande's Way: Changing Norms

An interesting article came my way yesterday:

* Gawande, Atul (2013): SLOW IDEAS, New Yorker, 29Jul13 --

"Slow Ideas" is about questions that trouble me to no end:  Why do some innovations spread fast? and how we could speed the ones that don't?

Atul Gawande tackles these in his chosen area of specialization: Medical Technology. He describes how Anesthesia was tested out for the first time in October 1846 by a dentist named William Morton, and how it spread "like a contagion, travelling through letters, meetings and periodicals". Within weeks the procedure had been passed on from Boston, across the Atlantic, to London and Paris. Within a year, it had become a standard procedure in hospitals across the world.

In sharp contrast, Joseph Lister's sterilization procedure spread at a snail's pace. Despite being the biggest cause of post-op deaths, the simple idea of excluding germs from the surgical field, using heat-sterilized instruments and surgical teams clad in sterile gowns and gloves, took more than 20 years to become popular.

Why?

Gawande lists possible reasons for this:

• Ideas that violate prior beliefs are harder to embrace  (germ theory seemed...so illogical!)
• Technical complexity -- taking a 'test drive' for gas-inhaled-anesthesia was easier than the painstaking attention to detail required for Lister's asepsis standards
• Visible immediate problem vs. invisible problem that pops up later (post-op infections)
• Makes life diffcult for the key player (Docs found scrubbing & cleaning a boring, time-consuming chore; gassing a patient was so simple!)

These days, a nation's health is indicated by two nifty acronyms - IMR and MMR - Infant Mortality Rate and Maternal Mortality Rate, respectively. Globally, 300,000 mothers and 6 million children die around the time of childbirth. In India, latest census reports (2011) indicate that MMR has come down to 212 per 100,000 births while IMR stands at 50 per 1000 live births. This is still far-far away from the Millenium Development Goals (MDGs) signed by India in 2000, under which we were to bring down these figures to 109 (MMR) and 29 (IMR) respectively, by 2015.

What went wrong? How is it that we are nowhere near achieving the targets?

Having seen some of our health sector projects in action, in Madhya Pradesh and Odisha, my own answer to this question had been that our medical administrative systems are riven by iron-clad hierarchies and biases. People at the cutting edge of service delivery - nurses, attendants, junior docs - get a raw deal from those sitting in far-away cities, in their cozy AC cabins. Few want to roll-up their sleeves and lead by example.

Gawande puts it nicely:

In the era of iPhone, FaceBook, and Twitter, we've become enamored of ideas that spread as effortlessly as ether. We want frictionless, "turnkey" solutions to the major difficulties of the world - hunger, disease, poverty. We prefer instructional videos to teachers, drones to troops, incentives to institutions. People and institutions can feel messy and anachronistic. They introduce, as the engineers put it, uncontrolled variability.

We yearn for frictionless, technological solutions. But people talking to people is still the way that norms and standards change.

Given our biases & hierarchies will merely talking be enough? -- most of the time, that seems to be the only thing we're doing!

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LINKS & REFERENCES

* Gawande, Atul (2013): SLOW IDEAS, New Yorker, 29Jul13 -- http://www.newyorker.com/reporting/2013/07/29/130729fa_fact_gawande?currentPage=all

India's IMR & MMR -- (ToI, 13May13) --http://articles.timesofindia.indiatimes.com/2013-05-13/india/39227265_1_india-imr-infant-mortality-rate
India Census Report - -Vital Stats 2011 -- http://censusindia.gov.in/vital_statistics/SRS_Bulletins/MMR_release_070711.pdf