Flight EK 565 was to land on the tarmac of Dubai International Airport. The view from thousands of feet above was amazing, with the coast line of Arabian Sea dotted with sand dunes. In Dubai, the vast stretch of blue waters was glowing under the blazing sun and looked extremely calm. Exactly a week back I was on the other side of Arabian Sea. And, almost 3000 kms apart in Calicut, she looked and behaved very differently. The tailwinds of monsoon had made her apparently dark, rough and turbulent. It was the erstwhile British Prime Minister Harold Wilson, who once mentioned that “a week is a long time in politics”. Well not just in politics, his words could be attributed to nature and life too.
The drive begins
There was no doubt that the next couple of days were going to be unforgettable. As I started the long drive from the Garden city to Calicut, the excitement of catching-up with good old mates on the silver jubilee anniversary of our MBBS batch was on overdrive. Twenty-five years back, a set of boys and girls with dreamy innocence, humble ambitions and seeds of compassion sowed in their minds were destined to be together for at least half a decade (though some loving hearts did choose to stay with each other for ever!). At the first traffic-light itself, one couldn’t help but notice the big hoarding of a leading super specialty hospital. This one, announcing their new branch in yet another up-market locality of the city. In fact, such hoardings are a common site across most towns and cities. While a large part of India struggles to find quality healthcare that is affordable and easily accessible, there is another segment where it’s common behavior that people walk in to a tertiary care centre even for minor ailments. But, is that the only irony of modern healthcare and health behavior?
Behavioral change is difficult, and changing health behaviors is no exception. Till about four years back, 61% of rural India was defecating in the open. This behavior leads to contamination of food, drinking water, and spreads diarrheal diseases that cause chronic malnutrition and childhood stunting, a burden that costs India 6.4% of its GDP, according to estimates of the World Bank. Culture, habits and inadequate infrastructure are significant reasons for open defecation in India and altering this behavior was always going to be a tough challenge. By launching the ‘Swachh Bharat Mission’ (SBM), the Prime Minister most importantly called out the ‘elephant in the room’. What followed may be an ideal example of behavior change, which was triggered through a mix of inspiration, awareness and resources. Since that pledge of 2014, almost 80 million household toilets are estimated to have been built till now. According to the director of the London School of Hygiene and Tropical Medicine, Val Curtis, “SBM is the biggest, most successful behavior-change campaign in the world”.
Unlike SBM, behavior change may be triggered by unexpected ‘shocks’ too, case in point being the recent Nipah outbreak in Kerala. Incidentally, Calicut was ‘ground zero’ for the crisis and it was in my alma mater, the Government Medical College, where patients were being contained. During the month of May 2018, when ‘Nipah fear’ was at its peak, there was a significant decrease in people visiting both private and government hospitals for the fear of the spread of Nipah virus. Has the Nipah effect induced any sustained behavior change amongst the population? Has the less crowding during those weeks led to reduction in the spreading of other communicable diseases? Two months down the lane many such questions remain that may need further analysis for conclusive answers. However, many foot soldiers of our healthcare system opine that even today, there is a significant reduction in patients reporting with minor ailments with as much as 50% less foot-falls in some districts. If this is sustainable and can be leveraged for the benefit of our three-tier healthcare system, only time will tell.
Meeting up with old mates was like a cocktail of bonhomie and nostalgia. The girls and boys of early nineties had evolved in to, I dare say, the who’s who of healthcare and clinical medicine across tiers and around the globe. But, despite this something was amiss at our reunion. All that changed, the moment Palliative care pioneer and Padma Shri Dr. M R Rajagopal took to the podium to deliver his guest oration. He brought the attention of his proud students to, probably, one of the biggest ironies of India today. Referring to a recent study published in the British Medical Journal, he pointed out that ‘Out-of-pocket’ health expenses has driven almost 55 million Indians into poverty in 2017. As per reports by WHO and World Bank, almost 100 million people a year are still forced to choose ‘between food and healthcare’. This is an irony that needs the urgent attention of not only the doctors but other stakeholders too. In this context, it may also be worthwhile to note the comments from James Crabtree, the author of "The Billionaire Raj". Supported by World Bank data, he points out that the number of Indians living in poverty is falling rapidly; from 125 million in 2016 to around 75 million today, to 20 million in 2022, and then dropping to near zero not long thereafter. Comparing the contrasting data points above, one can only wonder how much ‘avoidable’ healthcare expenditure is pulling us down as a nation, despite the rapid steps in eliminating poverty.
The last mile
After two days of camaraderie, the drive back from Calicut to the Deccan plateau had begun. Soon, the hustle and bustle of urban centers was behind me, and the early morning fog had brought with it an added dose of nostalgia. Those young mates of medical school who had left early to their heavenly abode were flashing in the mind. As the electronics of the car took over to see me safely through the winding roads of the Western Ghats, the audio was playing those unforgettable lines of Kishore-da:
“Raah pe rahate hai
Yaadon pe basar karte hai
Khush raho ahale watan
Hum to safar karte hai”
Very appropriate, I thought. May be, it was not the distance between coast lines that had made the Arabian sea look different. It could just be the distance from where I viewed her, from thousands of feet above sea level!
The author is Co-founder & Director @ BioQuest Solutions Pvt. Ltd, a Bangalore based MNC that has been partnering with clients across the life-sciences knowledge value chain since 2005.