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Beyond ice cream
Unfair to women
London Olympics |
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Threats to national security
A spooky encounter
Bridging the medical divide
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Beyond ice cream HOME
Minister P. Chidambaram’s comment that “we are prepared to pay rupees twenty for an ice cream cone but won’t pay one rupee more for a kilo of wheat or rice” has evoked sharp reactions from political parties and professional commentators on TV channels. The minister made the remark at Bangalore on Tuesday while talking to reporters about the impact of high food prices on the middle class. Calling the comment “scandalous”, the BJP says the minister has ridiculed the middle class. Behind politicking is a serious economic issue that needs to be understood. All finance ministers have to balance the needs of consumers and producers or farmers. Though there are annual hikes in the prices of wheat, rice and other food items, these are not enough to meet farmers’ rising costs of production. The government buys farm produce at high rates and sells it to the poor at subsidized prices. There are leakages in the distribution system which inflate the government’s food subsidy bill. Prices also rise due to inefficient food procurement, transportation and storage. Wheat and rice rot in rain because there is not enough space for scientific storage. Up to 40 per cent of fruits and vegetables perish in the absence of sufficient cold storage facilities. Cartels of middlemen manipulate food prices. One solution is to allow the entry of foreign retailers with deep pockets so that they set up cold storages and improve the supply chain to cut waste. But the middlemen’s champion, the BJP, opposes this. Ideally, the taxpayers’ money should be used to help the needy. However, better-off people also get subsidised diesel for SUVs and cheap cooking gas for kitchens. As a result, the subsidies have become unsustainable. The government has two options: either to reduce subsidies or raise taxes to fund them. If it raises petrol and diesel rates, only the users pay. If the government hikes indirect taxes, the poor too would be forced to pay. There is, therefore, the need to better target the subsidies, raise agricultural productivity and ensure better food storage and movement. Making noises over off-the-cuff remarks does not help.
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Unfair to women FRANCIS Bacon said women are synonymous with nature. Since nature is trampled upon in a thousand ways in the race for so-called development, women cannot be treated as an exception. And since natural resources have to be controlled for development, the control over fecundity of women is justified by the “development-oriented” machinery. It is a different matter that women could be given the right to exercise control over their fertility. Therefore, on World Population Day, the news of about 50 lakh women undergoing sterilisation every year at a young age of 25 should not come as a shock. Only in a Third World country about 77 per cent sterilisations can be done on women. It is no secret how multinationals use uninformed women of the Third World to conduct trials of hormonal drugs— both for enhancing fertility in rich countries and to reduce the population in developing countries like India. Women’s reproductive capacity has been a coveted area for the management of development plans. But these plans acquire inhuman proportions when they are linked with targets for sterilisation, as though the target of these plans is not a human being but a commodity. During the initial years of the family planning programme, in the sixties, vasectomy was carried out in sterilisation camps. This has totally been replaced now by tubectomy, which is carried out through laparoscopy, enabling a surgeon to do as many as 300 to 500 tubectomy operations within 10 hours, which works out to one operation every two minutes. This dangerous combination of attaining high targets quickly through sterilisation camps, with a reward for high achievers, is playing havoc with women’s health. Neither pre- surgery nor post- surgery care is accorded to these women. This kind of violence against women should be stopped. Controlling population is desirable, but tubectomy should be conducted after counselling, and after all other methods of family planning have failed.
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London Olympics AT the Beijing Olympic Games four years ago, the city seemed awash with Indian officials. One hundred and sixty-six of them, including politicians, bureaucrats and sports officials, had taken the trouble to travel to Beijing for a noble purpose. In their quest to run organise the perfect Commonwealth Games in 2010, they wanted to study the methods of the Beijing organisers. We did note what happened – the Beijing Olympics was perfection itself, the Commonwealth Games were a shambles. Obviously, no lessons were learnt in Beijing, except perhaps on how to buy Chinese goods in China. The cost of the visit to Beijing was quite high — Rs 2 crore. That proved to be just money down the drain. Sensibly, the government has pruned down the list from 166 in 2008 to 10 for the London Olympics. More sensibly still, most of them are sportspersons —Aslam Sher Khan, Viren Rasquinha, Ashok Kumar, PT Usha, Khazan Singh, Rohit Rajpal and Manisha Malhotra being some of them. The chef-de-mission of the Indian contingent is former hockey team captain Ajit Pal Singh. It’s not as if the politicians made this concession without a fight. Politicians, bureaucrats and officials of different sports federations had flooded the Indian Olympic Association with requests for accreditation for London-2012. The Indian Olympic Association wrote to the London organisers to provide them more tickets to meet the demand from the politicians, but its request was politely turned down. The Tamil Nadu and Kerala governments nominated their sports ministers to be part of the Indian delegation. Their offer to travel to London for the amelioration of sport was also turned down. Among the supporting staff, a repeat visitor from Beijing is Nasima Mirza, mother of Sania Mirza. Initially, she was described as a coach in media reports before the All-India Tennis Association (AITA) clarified that she was the manager of the team. Curiously enough, four years ago the same thing had happened – she was first designated the coach, then the manager. Why can’t they find a professional manager? India thrives on nepotism, but must the AITA have such blatant disregard for public opinion?
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A committee is a group that keeps minutes and loses hours. — Milton Berle
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Threats to national security IT was the inimitable Groucho Marx who got it right when he said, “It is very difficult to make predictions, especially about the future.” The record of the Indian intelligence agencies is near perfect in this regard. They could not anticipate the invasion of Kashmir by the ‘raiders’ in 1947; but that is excusable because of the confusion and disruption at that time due to the traumatic Partition of British India. Too many things were happening at the same time. However, the intelligence agencies could not anticipate the Pakistani assault on Kutch in April 1965, or Pakistan’s Operation Gibraltar later that year, which was designed to instigate a mass revolt in Kashmir that would be followed by a coup d’grace being delivered by the Pakistan Army. These feckless actions precipitated the India-Pakistan war of 1965 that ended in a draw with the honours being shared by both countries. Then we had the Indo-Pak war in 1971 that was on the cards after India decided to support the Mukti Bahini in May that year. War became almost inevitable after India deployed its forces in strength along the India-Pakistan border in the West in September-October in 1971. Plans were readied to invade East Pakistan. The initiative always lay in India’s hands, since Pakistan was, obligingly, making one mistake after the other. Like alienating all segments of the Bengali population in East Pakistan and incarcerating Sheikh Mujibur Rahman in West Pakistan, which added fuel to the Bengali revolt. The course of history would have been very different had General Yahya Khan released him at any stage of the insurrection, and offered to negotiate a settlement with him on autonomy for East Pakistan that could have been dragged on interminably. But, reverting to the actual conduct of the 1971 war, nothing should detract from the enormous victory gained in the East in what was a triumph cemented by India’s military engineers. However, India’s defensive posture in the West failed to anticipate the Pakistani assault that led to the loss of valuable territory in Chamb across the Munawar Tawi, rendering communications between Jammu and Poonch-Rajouri precarious. Likewise, the bold Pakistani thrust across the international border in the Rajasthan sector was not anticipated, and their offensive was only blunted by the Indian Air Force; fortunately Pakistan did not utilise its own Air Force for reasons that still remain unclear. But it is surprising that the location of an entire Pakistani division remained unknown till the end of the operations. The short point being made here is that with all the time and resources available to them, India’s intelligence and security agencies have repeatedly failed to assess the threat accurately. The facts were available; their collation was effected; what failed was their assessment in a realistic time-frame. Predictions about the future are, indeed, difficult, and nothing illustrates this better than the huge failure to anticipate the widespread intrusions across the Line of Control that precipitated the Kargil conflict over May-July 1999. There was little reason for the intelligence agencies and the security forces to have been carried away by the bonhomie following the Lahore Agreement in February that year. Nothing else can explain why normal vigilance was relaxed, patrolling along the border relaxed and cross-LOC intelligence operations either stopped or downgraded. The basic problem, however, lies elsewhere. The problem lies in the basic ‘conception,’ which often provides the framework for all thinking in the agencies. For example, the ‘conception’ before the Sino-Indian border conflict in 1962, framed by Jawaharlal Nehru and Krishna Menon, was that the Chinese would never attack. Four decades later the dominating ‘conception’ was that the Line of Control was impassable in winter; hence, cross-border intrusions at that time of the year were unthinkable. The history of intelligence failures ranging from the Trojan Horse incident to Pearl Harbor to the Kargil conflict informs us that they occur because an operating ‘conception’ informs the victim-country, but the aggressor dares to think the unthinkable. More importantly, intelligence failures occur at the levels of analysis and assessment, not information collection or its collation. The lesson to be drawn from this narrative is that threats to national security must be constantly reviewed. It cannot remain a one-time exercise, with the assessment made being cast in stone. Here, the old shibboleth bears reiterating that intelligence agencies cannot brag about their successes, since this might compromise their sources. Therefore, the agencies do not get any credit for nine successes achieved, but everyone remembers their one failure. Especially, when it comes to dealing with terrorism. The number of terrorist modules wrapped up can never be published, whereas terrorist attacks make the headlines and are flashed across the world. Still, the known intelligence failures mentioned above have proven very costly. The problem is that everything said about such matters by either the agencies or their critics has to be taken on trust. Regrettably, India has no modalities for parliamentary control over the agencies. Another issue: why are the assessments made regarding the security threat not published as White Papers or Posture Statements? Comments and criticisms from the informed public could prove invaluable to educate the decision-makers. Moreover, outsider views could also question any ‘conceptions’ afflicting the intelligence agencies while strengthening the sinews of Indian democracy. A singular irony obtaining in India is that the Prime Minister keeps repeating that the internal security threat has become the greatest challenge facing the country. But all the National Security Advisers, save one, have come from the Foreign Service, with only a nodding acquaintance of such issues. Besides, the non-traditional threats to national security like migration, environmental decay, food, water and energy security have become equally, if not more, significant than traditional security. It would be interesting to know how much time the agencies bestow on these non-traditional security issues in comparison to their perennial attention devoted to Pakistan and China and nuclear weapons. Lest this picture seem overdrawn, a reference is possible to the address by Robert Gates, former Secretary of Defense in the United States, to West Point graduates in November 2011. He said: “We can’t know with absolute certainty what the future of warfare will hold… Just think about the range of security challenges we face right now beyond Iraq and Afghanistan: terrorism and terrorists in search of weapons of mass destruction, Iran, North Korea, military modernisation programmes in Russia and China, failed and failing states, revolution in the Middle East, cyber piracy, proliferation, natural and man-made disasters. And I must tell you, when it comes to predicting the nature and location of our next military engagements, since Vietnam, our record has been perfect. We have never once gotten it right….” India can console itself with citing the ‘perfect’ American record. Or, it could think through its problems, and how it might succeed in getting the threat right for
itself.
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A spooky encounter THE high school examinations had just got over. It was now a long wait for the results. We four buddies used to sit on a drain overbridge in Lucknow’s Adarsh Nagar till late in the night, keeping a vigil for the cry of the hawker announcing the results. Yes, in those days — I am talking about 1962 — special result supplements, brought out by newspaper establishments, used to be printed in the middle of the night with the hawkers making a fast buck in the small hours of the day. As we sat cracking jokes, a neighbourhood uncle joined us. He had a penchant for telling ghost stories. Within minutes, this uncle had occupied the centre seat and was reeling away his encounters with ghosts. Narrating his “bhoot” encounters, he said once a tall white figure had saved him from an accident. But he also talked about the witch which was a regular at the graveyard and could always be spotted sitting on the big tree in the centre of the graveyard. He warned us not to visit the graveyard after sunset. The ghost uncle had barely finished sermonising, virtually challenging us, when Ravi, one of our friends, chipped in: “Bunkus, there is no such thing as ghost, witch or ‘bhoot’. Uncle, it is just a creation of your imagination. I will go to the graveyard and hammer a nail in the root of that tree at midnight.” “Forget it ‘yaar’, why are we getting into this ‘bhoot’ business?” I said trying to salvage the situation. But Ravi was adamant. He folded his green ‘lungi’ up to the knees and walked away. But he was back soon with a hammer and a nail box. The sound of the Central Jail gong heralding 11 pm was loud and clear. We soon set off on our mission to the graveyard, the “bhoot uncle” also in tow. I tried to reason with Ravi. But he was determined to prove the ghost theory wrong. I and Surinder, another friend, agreed to accompany Ravi inside the graveyard. As Ravi marched towards the big tree, Surinder and I suddenly froze in our steps. Gazing down at us, barely 100 metres away, were a pair of 50 sparkling eyes. The wail of a dog added to the spooky feeling sending a chill down my spine on that hot summer night. By then Ravi had reached the root jutting out from the ground. The blow of the hammer on the nail head shattered the silence of the night. The 50 pair of eyes seemed to sway. That was enough! The two of us shouted: “Bhag, Ravi bhag.” The next thing I recollect is that Ravi got up, screamed and then collapsed. Our “bhoot uncle” came running towards us, a big torch in hand. Ravi was mumbling, “the bhoot is holding on to my lungi.” A flash of the torch light on the ‘lungi’ unveiled the culprit. Yes, Ravi had hammered the nail into the tree root along with the ‘lungi’. He said: “With you two shouting ‘bhaag’, I got up to run towards you, but could not. The fear of having been caught by the ‘bhoot’ was enough to experience a black-out.” According to “bhoot uncle”, the glowing eyes in the distance belonged to a pack of jackals who were regular visitors to the graveyard, expecting a
fill.
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Bridging the medical divide This problem is further magnified in India due to migration of most doctors to either urban areas and/or foreign countries. In the past 65 years since Independence, a number of measures like getting a bond of rural service filled at the time of admission into medical college, incentives like admission into PG courses, mandatory provision of initial years of government service in rural areas, the focused programs like national rural health mission etc. have been tried, but none has been really able to find a permanent solution to this problem. The recent proposal of starting a new course, Bachelor of Rural Healthcare (BRHC), for duration of three-and- half-years, is under active consideration of the government. There are already arguments and counter-arguments regarding this course. The proponents believe that since the BRHC graduates will be licensed to only practice in rural areas, this may solve the problem. However, others feel that the BRHC graduates may be inadequately trained with course duration of three-and- a-half-years, in comparison to the MBBS course of five-and-a-half years. This will provide sub-optimal medical services to rural patients and may result in setting up of different standards of healthcare services between the rural and the urban patients. Rural inhabitants, too, have the same right to quality health services as do the urban patients. Moreover, the line between an urban area and a rural area is quite thin thus the restriction of practice of BRHC graduates to only rural areas may be difficult. The creation of this new cadre of so-called mid-level healthcare providers is not new globally. In some countries, such cadres with a different nomenclature already exist, called “physician’s assistants” in USA and “clinical officers” in Tanzania. In South Africa, such mid-level workers are trained in medical schools as a part of family medicine training with maximum emphasis on skill training. Their role in promoting public health is well established but they always work under the supervision of a medical doctor. Inequitable distribution In the international scenario, there have been scientific insights into the problem of inequitable distribution of health services in the urban and rural areas. There are numerous factors behind this such as difficult living conditions in villages with the lack of basic amenities and poor educational opportunities for their children, poor recreational infrastructure, and inadequate accommodation facilities etc. Others reasons like limited employment opportunities for the spouse. Academic isolation and lack of consultant support, too, add to their woes. There are still additional factors like insufficient number of relievers whenever leave is required by rural doctors, poor physical infrastructure in hospitals, and inadequate access to medical equipment and drugs have been found to be responsible for poor interest of doctors in the villages. In India, other factors like poor accessibility due to lack of transportation facilities and inadequate basic amenities like potable water and erratic supply of electricity are other limiting factors. Ironically, rather than giving more financial incentives to those who serve in the villages, the salary of the rural healthcare workers in our country is less due to lower rate of house rent allowance in the villages in comparison to the bigger cities. Most countries in the world have formulated policies on the basis of scientific evidence to solve this problem. Some of the scientific evidence available in literature that has been reported to have an impact on this problem is: Colleges in rural areas A number of studies have shown that the doctors trained in rural medical colleges tend to serve rural areas better. Studies from Canada, China and Congo have reported that medical graduates from rural-based medical schools serve in rural areas to the extent of 30.7 per cent, 34 per cent and 81.3 per cent, respectively. Reports from Australia by Hays and Bowman separately have also concluded that the existence of rural medical schools should be a major strategy to increase the distribution of doctors in the rural areas. Opening of medical colleges in rural areas have been reported to provide multi-fold advantages: n The establishment of a medical school means provision of tertiary-care health services to the area. Thus the problem of lack of medical services is eliminated directly. n The rural medical school provides huge employment opportunities to local inhabitants, raising their financial standard. n The medical school brings many ancillary service providers like chemist shops, private laboratories, diagnostic centres, transport providers like taxis etc., private lodges/ hotels/ guest houses, which will result in the overall development of the area. n Some health planners argue that rural medical schools are unlikely to attract highly talented medical faculty. But this has not been the case, as proved by various scientific studies. Moreover, the success stories of two of the top medical institutions of India — Christian Medical College (CMC), Vellore, and Kasturba Medical College (KMC), Mangalore, located in rural areas in Tamil Nadu and Karnataka, respectively, prove that the provision of academic work culture and the state-of-the-art infrastructure brings in true hardcore professionals defying the barriers of hefty salaries and other urban amenities. Rural students As per existing evidence, students from a rural background (who have completed primary or secondary education from rural schools) are four to six times more likely to practice in rural areas than city-bred peers. The potential impact of this observation was quantified by Rabinowitz in a longitudinal study performed under the Physician Shortage Area Program (PSAP) in the USA. On statistical analysis, rural background was the single variable strongly associated with rural practice. Gender bias Male doctors have been reported to more likely serve in the rural areas than the females. Does it mean that more men should be encouraged to join medical profession than the women? The answer is ‘no’ because the creation of better and safe working conditions for women in the rural areas will remove this problem. Aptitude Assessing the aptitude for serving the rural areas at the time of admission into the medical profession has shown to produce more doctors who will serve in rural areas. Thus, the introduction an aptitude test at the time of entrance examination of medical students may help to bring more students into the medical profession with a better flare for serving in the villages. Specialist courses Starting postgraduate programmes in rural medicine/ family medicine has shown positive results for producing the dedicated doctors to serve in the rural areas. In the presence of some antagonistic thoughts of inadequate training in the proposed three-and- a-half-year course of Bachelor in Rural Health Course in India, the option of introduction of MBBS course with an honours degree in rural/ family medicine may be explored. Special scholarships Provision of scholarships for students from a poor socio-economic background with an agreement to serve in the rural areas would also help in promoting rural medical practice. Although evidence supporting the value of interventions to promote the placement of doctors in rural areas is limited, many countries have, however, already successfully used it. Ironically, in developing countries, where the rural population constitutes approximately 70-80 per cent of the entire population, the problem seems to be worsening. Evidence, though limited, clearly indicates that the strategies of incentives and coercion address only short-term needs with little or even negative long-term impact. The role of selecting more students from rural background and opening of more medical colleges in the rural setting is strongly supported by the literature. The recent decision of the government to start six new AIIMS-like institutions in big cities namely Patna, Bhopal, Jodhpur, Rishikesh, Bhubaneswar and Raipur, is a welcome step towards improving the overall standards of health and medical education in the country. However, in future, if such high-end medical institutions are based in rural areas, it may help in narrowing down the gap between the urban and the rural areas to some extent. The writer is a Professor of Orthopaedics, Government Medical College Hospital, Sector 32, Chandigarh
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SHORTAGE of healthcare professionals in rural areas is a global problem. Both developed and developing countries have been facing the problem of skewed distribution of doctors towards the urban areas. Though it is the rural population that needs and deserves these doctors more — being usually more sick, poor and less educated than their counterparts in urban areas. The discrepancy between the needs and the delivery of services proves Hart’s “inverse care law”, which states that the ones with greatest needs usually have the worst provision of medical services. 