Tag: The Lancet

On The Lancet editorial

On May 8, The Lancet published an editorial criticising the Narendra Modi government’s response to India’s second COVID-19 outbreak, which has been redefining the meaning of ‘snafu’. All hell broke loose. Of course, hell has been breaking loose for quite some time in India now, but the latest episode was in one specific sense also gratifying to behold.

There were the usual rumbles in the week following the editorial’s appearance, until on May 17 India’s health minister Dr Harsh Vardhan shared a blog post penned by a Pankaj Chaturvedi deriding The Lancet‘s choice of arguments. (I’m fond of emboldening the honorific: it shows doctors can be stupid, too.) The post is mostly whataboutery studded with a few gems about how people who liked the editorial aren’t pissed enough that favipiravir and hydroxychloroquine were approved for use – as Dr Vardhan’s ministry did. More importantly, it seems Dr Vardhan, and his colleagues in fact, threw themselves into the barrel looking for anything with fully formed sentences that said The Lancet was wrong – a sign that their government still gives a damn about what foreign journals, and perhaps magazines and newspapers too, say about it.

We need to use this to the fullest extent, and I daresay that it’s the sort of resource the government is going to find difficult to duplicate as well. There was recently an article about Modi doing a great job during India’s second wave, published in an outlet called The Daily Guardian. There was enough confusion to draw the UK’s The Guardian forward and clarify that it was an unaffiliated entity – but no amount of confusion can supplant an institution, no matter how illiberal. Aakar Patel wrote in 2018: “The fact is that intelligent and intellectual bigotry is very difficult. There are very few people who can pull that off and that is why we can count the major ones on our fingers.” This is also why the government has twitched every time the New York Times, the Washington Post, BBC, The Lancet, Science and The BMJ have published articles critical of India, even if this isn’t the full picture.

It’s doubly interesting that the sophistry of the rejoinders aside, Dr Vardhan, his colleagues in government and his party’s supporters have all been antagonised by what they perceive to be a political act by a medical journal. This is an untenable distinction, of course – one that fantasises about a clear divide between the Watchers, who look out, and the Watched, who dare not know what the Watchers see. More pertinently, it’s a reflection of what they desperately expect from their own compatriots: to ignore how bad political leadership could help a virus ravage hundreds of thousands of families.

Laurie Penny wrote an essay in 2018 with some life-saving prescriptions, including that victories against fascists can never be had in the realm of reason. But when The Lancet publishes an editorial, The BMJ the work of an investigative reporter or even The Economist a tightly worded admonishment, they’re both reasoning and enacting a theatre of reason, and the latter seems to bother right-wing ideologues. These people are not going to heed reason, not now and not ever, but it’s heartening, even if my hope is naïve or misplaced, that they’re tractable in some meagre measure… less like dark matter and more like neutrinos.

Featured image credit: Kunj Parekh/Unsplash.

A non-self-correcting science

While I’m all for a bit of triumphalism when some component of conventional publication vis-à-vis scientific research – like pre-publication anonymous peer review – fails, and fails publicly, I spotted an article in The Conversation earlier today that I thought crossed a line (and not in the way you think). In this article, headlined ‘Retractions and controversies over coronavirus research show that the process of science is working as it should’, the author writes:

Some people are viewing the retractions [by The Lancet and the New England Journal of Medicine] as an indictment of the scientific process. Certainly, the overturning of these papers is bad news, and there is plenty of blame to go around. But despite these short-term setbacks, the scrutiny and subsequent correction of the papers actually show that science is working. Reporting of the pandemic is allowing people to see, many for the first time, the messy business of scientific progress.

The retraction of the hydroxychloroquine paper … drew immediate attention not only because it placed science in a bad light, but also because President Trump had touted the drug as an effective treatment for COVID-19 despite the lack of strong evidence. Responses in the media were harsh. … [Their] headlines may have [had] merit, but perspective is also needed. Retractions are rare – only about 0.04% of published papers are withdrawn – but scrutiny, update and correction are common. It is how science is supposed to work, and it is happening in all areas of research relating to SARS-CoV-2.

If you ask me, this is not science working as it should. This is the journals that published the papers discovering that the mechanisms they’d adopted that they’d said would filter fraudulent papers letting fraudulent papers slip through.

But by the author’s logic, “this is science working as it should” would encompass any mistake that’s later discovered, followed by suitable corrective action. This is neither here nor there – and more importantly it allows broken processes to be subsumed under the logic’s all-encompassing benevolence. If this is scientific publishing as it should be, we wouldn’t have to think deeply about how we can fix anonymous pre-publication peer-review because it wouldn’t be broken. However, we know in reality that it is.

If anything, by advancing his argument, the author has cleverly pressed an argumentative tack that supporters of more progressive scientific publishing models in the service of preserving the status quo. Instead, we need to acknowledge that an important part of science, called science publishing, has evolved into a flawed creature – so that we can set about bending the moral arc towards fixing it. (We already know that if we don’t acknowledge it, we won’t fix it.)

The costs of correction

I was slightly disappointed to read a report in the New York Times this morning. Entitled ‘Two Huge COVID-19 Studies Are Retracted After Scientists Sound Alarms’, it discussed the implications of two large studies of COVID-19 recently being retracted by two leading medical journals they were published in, the New England Journal of Medicine and The Lancet. My sentiment stemmed from the following paragraph and some after:

I don’t know if just these two retractions raise troubling questions as if these questions weren’t already being asked well before these incidents. The suggestion that the lack of peer-review, or any form of peer-review at all in its current form (opaque, unpaid) could be to blame is more frustrating, as is the article’s own focus on the quality of the databases used in the two studies instead of the overarching issue. Perhaps this is yet another manifestation of the NYT’s crisis under Trump?

One of the benefits of the preprint publishing system is that peer-review is substituted with ‘open review’. And one of the purposes of preprints is that the authors of a study can collect feedback and suggestions before publishing in a peer-reviewed journal instead of accruing a significant correction cost post-publication, in the form of corrections or retractions, both of which continue to carry a considerable amount of stigma. So as such, the preprints mode ensures a more complete, a more thoroughly reviewed manuscript enters the peer-review system instead of vesting the entire burden of fact-checking and reviewing a paper on a small group of experts whose names and suggestions most journals don’t reveal, and who are generally unpaid for their time and efforts.

In turn, the state of scientific research is fine. It would simply be even better if we reduced the costs associated with correcting the scientific record instead of heaping more penalties on that one moment, as the conventional system of publishing does. ‘Conventional – which in this sphere seems to be another word for ‘closed-off’ – journals also have an incentive to refuse to publish corrections or perform retractions because they’ve built themselves up on claims of being discerning, thorough and reliable. So retractions are a black mark on their record. Elisabeth Bik has often noted how long journals take to even acknowledge entirely legitimate complaints about papers they’ve published, presumably for this reason.

There really shouldn’t be any debate on which system is better – but sadly there is.

A caveat for peer-review

Now that more researchers are finding more holes in the study in The Lancet, which claimed hydroxychloroquine – far from being a saviour of people with COVID-19 – actually harms them, I wonder where the people are who’ve been hollering that preprint servers be shut down because they harm people during a pandemic.

The Lancet study, entitled ‘Hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19: a multinational registry analysis’, was published online on May 22, 2020. Quoting from the section on its findings:

After controlling for multiple confounding factors (age, sex, race or ethnicity, body-mass index, underlying cardiovascular disease and its risk factors, diabetes, underlying lung disease, smoking, immunosuppressed condition, and baseline disease severity), when compared with mortality in the control group, hydroxychloroquine, hydroxychloroquine with a macrolide, chloroquine, and chloroquine with a macrolide were each independently associated with an increased risk of in-hospital mortality. Compared with the control group, hydroxychloroquine, hydroxychloroquine with a macrolide, chloroquine, and chloroquine with a macrolide were independently associated with an increased risk of de-novo ventricular arrhythmia during hospitalisation.

I assume it was peer-reviewed. According to the journal’s website, there is an option for researchers to have their submission fast-tracked if they’re so eligible (emphasis added):

All randomised controlled trials are eligible for Swift+, our fastest route to publication. Our editors will provide a decision within 10 working days; if sent for review this will include full peer review. If accepted, publication online will occur within another 10 working days (10+10). For research papers, which will usually be randomised controlled trials, judged eligible for consideration by the journal’s staff will be peer-reviewed within 72 h and, if accepted, published within 4 weeks of receipt.

The statistician Andrew Gelman featured two critiques on his blog, both by a James Watson, on May 24 and May 25. There are many others, including from other researchers, but these two provide a good indication of the extent to and ways in which the results could be wrong. On May 24:

… seeing such huge effects really suggests that some very big confounders have not been properly adjusted for. What’s interesting is that the New England Journal of Medicine published a very similar study a few weeks ago where they saw no effect on mortality. Guess what, they had much more detailed data on patient severity. One thing that the authors of the Lancet paper didn’t do, which they could have done: If HCQ/CQ is killing people, you would expect a dose (mg/kg) effect. There is very large variation in the doses that the hospitals are giving … . Our group has already shown that in chloroquine self-poisoning, death is highly predictable from dose. No dose effect would suggest it’s mostly confounding. In short, it’s a pretty poor dataset and the results, if interpreted literally, could massively damage ongoing randomised trials of HCQ/CQ.

On May 25:

The study only has four authors, which is weird for a global study in 96,000 patients (and no acknowledgements at the end of the paper). Studies like this in medicine usually would have 50-100 authors (often in some kind of collaborative group). The data come from the “Surgical Outcomes Collaborative”, which is in fact a company. The CEO (Sapan Desai) is the second author. One of the comments on the blog post is “I was surprised to see that the data have not been analysed using a hierarchical model”. But not only do they not use hierarchical modelling and they do not appear to be adjusting by hospital/country, they also give almost no information about the different hospitals: which countries (just continent level), how the treated vs not treated are distributed across hospitals, etc.

(Gelman notes in a postscript that “we know from experience that The Lancet can make mistakes. Peer review is nothing at all compared to open review.” – So I’m confident the study’s paper was peer-reviewed before it was published.)

Perhaps it’s time we attached a caveat to claims drawn from peer-reviewed papers: that “the results have been peer-reviewed but that doesn’t have to mean they’re right”, just as journalists are already expected to note that “preprint papers haven’t been peer-reviewed yet”.

Poor journalism is making it harder for preprints

There have been quite a few statements by various scientists on Twitter who, in pointing to some preprint paper’s untenable claims, point to the manuscript’s identity as a preprint paper as well. This is not fair, as I’ve argued many times before. A big part of the problem here is bad journalism. Bad preprint papers are a problem not because their substance is bad but because people who are not qualified to understand why it is bad read it and internalise its conclusions at face value.

There are dozens of new preprint papers uploaded onto arXiv, medRxiv and bioRxiv every week making controversial arguments and/or arriving at far-fetched conclusions, often patronising to the efforts of the subject’s better exponents. Most of them (at least according to what I know of preprints on arXiv) are debated and laid to rest by scientists familiar with the topics at hand. No non-expert is hitting up arXiv or bioRxiv every morning looking for preprints to go crazy on. The ones that become controversial enough to catch the attention of non-experts have, nine times out of then, been amplified to that effect by a journalist who didn’t suitably qualify the preprint’s claims and simply published it. Suddenly, scores (or more) of non-experts have acquired what they think is refined knowledge, and public opinion thereafter goes against the scientific grain.

Acknowledging that this collection of events is a problem on many levels, which particular event would you say is the deeper one?

Some say it’s the preprint mode of publishing, and when asked for an alternative, demand that the use of preprint servers be discouraged. But this wouldn’t solve the problem. Preprint papers are a relatively new development while ‘bad science’ has been published for a long time. More importantly, preprint papers improve public access to science, and preprints that contain good science do this even better.

To making sweeping statements against the preprint publishing enterprise because some preprints are bad is not fair, especially to non-expert enthusiasts (like journalists, bloggers, students) in developing countries, who typically can’t afford the subscription fees to access paywalled, peer-reviewed papers. (Open-access publishing is a solution too but it doesn’t seem to feature in the present pseudo-debate nor does it address important issues that beset itself as well as paywalled papers.)

Even more, if we admitted that bad journalism is the problem, as it really is, we achieve two things: prevent ‘bad science’ from reaching the larger population and retain access to ‘good science’.

Now, to the finer issue of health- and medicine-related preprints: Yes, acting based on the conclusions of a preprint paper – such as ingesting an untested drug or paying too much attention to an irrelevant symptom – during a health crisis in a country with insufficient hospitals and doctors can prove deadlier than usual. But how on Earth could a person have found that preprint paper, read it well enough to understand what it was saying, and act on its conclusions? (Put this way, a bad journalist could be even more to blame for enabling access to a bad study by translating its claims to simpler language.)

Next, a study published in The Lancet claimed – and thus allowed others to claim by reference – that most conversations about the novel coronavirus have been driven by preprint papers. (An article in Ars Technica on May 6 carried this provocative headline, for example: ‘Unvetted science is fuelling COVID-19 misinformation’.) However, the study was based on only 11 papers. In addition, those who invoke this study in support of arguments directed against preprints often fail to mention the following paragraph, drawn from the same paper:

… despite the advantages of speedy information delivery, the lack of peer review can also translate into issues of credibility and misinformation, both intentional and unintentional. This particular drawback has been highlighted during the ongoing outbreak, especially after the high-profile withdrawal of a virology study from the preprint server bioRxiv, which erroneously claimed that COVID-19 contained HIV “insertions”. The very fact that this study was withdrawn showcases the power of open peer-review during emergencies; the withdrawal itself appears to have been prompted by outcry from dozens of scientists from around the globe who had access to the study because it was placed on a public server. Much of this outcry was documented on Twitter and on longer-form popular science blogs, signalling that such fora would serve as rich additional data sources for future work on the impact of preprints on public discourse. However, instances such as this one described showcase the need for caution when acting upon the science put forth by any one preprint.”

The authors, Maimuna Majumder and Kenneth Mandl, have captured the real problem. Lots of preprints are being uploaded every week and quite a few are rotten. Irrespective of how many do or don’t drive public conversations (especially on the social media), it’s disingenuous to assume this risk by itself suffices to cut access.

Instead, as the scientists write, exercise caution. Instead of spoiling a good thing, figure out a way to improve the reporting habits of errant journalists. Otherwise, remember that nothing stops an irresponsible journalist from sensationalising the level-headed conclusions of a peer-reviewed paper either. All it takes is to quote from a grossly exaggerated university press-release and to not consult with an independent expert. Even opposing preprints with peer-reviewed papers only advances a false balance, comparing preprints’ access advantage to peer-review’s gatekeeping advantage (and even that is on shaky ground).

Distracting from the peer-review problem

From an article entitled ‘The risks of swiftly spreading coronavirus research‘ published by Reuters:

A Reuters analysis found that at least 153 studies – including epidemiological papers, genetic analyses and clinical reports – examining every aspect of the disease, now called COVID-19 – have been posted or published since the start of the outbreak. These involved 675 researchers from around the globe. …

Richard Horton, editor-in-chief of The Lancet group of science and medical journals, says he’s instituted “surge capacity” staffing to sift through a flood of 30 to 40 submissions of scientific research a day to his group alone.

… much of [this work] is raw. With most fresh science being posted online without being peer-reviewed, some of the material lacks scientific rigour, experts say, and some has already been exposed as flawed, or plain wrong, and has been withdrawn.

“The public will not benefit from early findings if they are flawed or hyped,” said Tom Sheldon, a science communications specialist at Britain’s non-profit Science Media Centre. …

Preprints allow their authors to contribute to the scientific debate and can foster collaboration, but they can also bring researchers almost instant, international media and public attention.

“Some of the material that’s been put out – on pre-print servers for example – clearly has been… unhelpful,” said The Lancet’s Horton.

“Whether it’s fake news or misinformation or rumour-mongering, it’s certainly contributed to fear and panic.” …

Magdalena Skipper, editor-in-chief of Nature, said her group of journals, like The Lancet’s, was working hard to “select and filter” submitted manuscripts. “We will never compromise the rigour of our peer review, and papers will only be accepted once … they have been thoroughly assessed,” she said.

When Horton or Sheldon say some of the preprints have been “unhelpful” and that they cause panic among the people – which people do they mean? No non-expert person is hitting up bioRxiv looking for COVID-19 papers. They mean some lazy journalists and some irresponsible scientists are spreading misinformation, and frankly their habits represent a more responsible problem to solve instead of pointing fingers at preprints.

The Reuters analysis also says nothing about how well preprint repositories as well as scientists on social media platforms are conducting open peer-review, instead cherry-picking reasons to compose a lopsided argument against greater transparency in the knowledge economy. Indeed, crisis situations like the COVID-19 outbreak often seem to become ground zero for contemplating the need for preprints but really, no one seems to want to discuss “peer-reviewed” disasters like the one recently publicised by Elisabeth Bik. To quote from The Wire (emphasis added),

[Elisabeth] Bik, @SmutClyde, @mortenoxe and @TigerBB8 (all Twitter handles of unidentified persons), report – as written by Bik in a blog post – that “the Western blot bands in all 400+ papers are all very regularly spaced and have a smooth appearance in the shape of a dumbbell or tadpole, without any of the usual smudges or stains. All bands are placed on similar looking backgrounds, suggesting they were copy-pasted from other sources or computer generated.”

Bik also notes that most of the papers, though not all, were published in only six journals: Artificial Cells Nanomedicine and Biotechnology, Journal of Cellular Biochemistry, Biomedicine & Pharmacotherapy, Experimental and Molecular Pathology, Journal of Cellular Physiology, and Cellular Physiology and Biochemistry, all maintained reputed publishers and – importantly – all of them peer-reviewed.

Caste, healthcare and statistics

In late November 2014, the esteemed British medical journal The Lancet published an editorial calling for the end of casteism in India to mitigate the deteriorating health of the millions of rural poor, if nothing else. The central argument was that caste was hampering access to healthcare services. Caste has been blamed for hampering many things. As Amartya Sen and Jean Dreze write in An Uncertain Glory (2014), “… caste continues to be an important instrument of power in Indian society, even where the caste system has lost some of its earlier barbarity and brutality”.

To append healthcare to that list wasn’t a big leap because casteism in India has had a tendency to graduate access to the fundamental rights even. The editorial cites a lecture that the social activist Arundhati Roy gave last year, during which she mentions the example of a doctor who wouldn’t treat a patient because the latter is of a lower caste. At the same time, the appending had to be a controversial leap because it implies that those who are responsible for the ineffectual provision of healthcare services could in some way be ignoring – or even abetting – casteist practices.

Anyway, three responses to the editorial (whose links are available on the same page) provide some clarity on how caste contributes directly and indirectly to the country’s distinct health problems by interfering in unique ways with our class divisions, economic conditions and social inequalities. They can be broadly grouped as age, inheritance and wealth.

1. Age

The first letter argues that the health effects of caste are best diagnosed among older people, who have been exposed to poverty and the effects of caste for a lifetime. Citing this study (PDF), the correspondents write:

The study reported that several health measures, including self-rated overall general health, disability, and presence of a chronic disorder, are similar between scheduled tribes, scheduled castes, Brahmins, Kshatriyas, Vaishyas, and Shudras in people aged 18–49 years. However, people aged 50 years and older in scheduled tribes and castes were reported as having poorer self-rated health and generally higher levels of disability than those in less impoverished groups, which suggests that the longer the exposure to poverty, the greater the effect on the ageing process.

However, there is an obvious problem in assessing older people and attributing health concerns unique to their age to a single agent. Hindus, who comprise the religious majority in India, traditionally revere their elders. The young are openly expected to ensure that their elders’ economic security and social dignity are not significantly diminished once they retire from full-time employment. Such promises on the other hand are not prevalent in other religious groups. To be sure, that “longer exposure to poverty leads to more health drawbacks” is not entirely flawed but the intensity of its effects may be confounded by traditional values.

2. Inheritance

A paragraph from the second letter reads,

People should only marry within their caste, which can lead to consanguinity. This antiquated tradition has resulted in an unusually high prevalence of specific autosomal recessive diseases in specific community or caste populations, such as diabetes, hypertension, ischaemic heart disease, mental impairments, mental illness, spinocerebellar ataxia, thalassaemia, and sickle-cell diseases.

While increasing literacy rates, especially among the younger age groups, are likely to reduce caste gaps in literacy over this decade, caste seems to have left some population groups with an unenviable inheritance: of the effects of detrimental biological practices. One of the studies the letter’s authors cite provides a p-value of 0.01 for consanguinity being a determinant of diabetic retinopathy (that’s strong evidence). And inter/intra-caste marriages are a prominent feature among caste-based social groups.

3. Wealth

The author of the third piece of correspondence is disappointed that The Lancet saw fit to think dismal healthcare has anything to do with caste, and then adds that the principal determinant across all castes is economic status (on the basis of a 2010 IIPS study). In doing so, two aspects of the caste-healthcare association are thrown up. First, that casteism’s effects are most pronounced on the economic statuses of those victimized by its practice, and that is one way of understanding its effects on access to reliable healthcare. Second, that the statistical knife cuts the other way, too: how do you attribute an effect to caste when it could just as well be due to a failure of some other system?

Three overlooked reasons why India’s healthcare indicators remain abysmal

Scroll.in
January 2, 2015

The Bharatiya Janata Party-led Central government announced in July that it would roll out a National Health Assurance Mission, whose aim would be to provide some free medical services to reduce “out of pocket spending on healthcare by the common man”.

It is thought that the NHAM could be active as early as this month, and could cost $26 billion, according to a senior health official. This is a noble gesture: according to a report on healthcare costs in the BRICS countries (Brazil, Russia, India, China and South Africa), out-of-pocket expenditure pushed as many as 60 million Indians below the poverty line in 2010.

Going by a Planning Commission report accessed in May, India spends only 1.04% of its GDP on publicly-funded health, while its total health expenditure (public and private) was 4% in 2010-2014. The same report aspired to increase public health spending to 3% of GDP by 2020 and to 4% by 2025. A lot has changed since then, especially when the Narendra Modi government cut down the health spending by $900 million for 2014-2015 citing lack of funds.

Nonetheless, the reason India’s healthcare indicators remain abysmal is not just a question of money (after all, ours is one of the fastest growing economies). The problem is a persistent rash of doublespeak that denies the people a coherent healthcare system. While successive governments have committed to various goals, no government programme has yet focused on the three most important problems facing India’s health at once: a mismanaged regulatory climate, corruption, and the caste system.

1. Contradictory regulations

The problems with regulation are illustrated by India’s medical tourism industry, which according to government sources will be worth Rs 9,500 crore in 2015, and as much as Rs 54,000 crore in 2020. Almost 75% of the medical imaging equipment (worth Rs 18,000 crore in 2011) that services this industry is imported and the value of imports themselves grew at a compounded rate of 16% in 2010-2014.

There is an import duty on fully-finished devices to the tune of 10%, whose cost is transferred to consumers. It gets better here: if device components are imported individually and then assembled in India, there is an additional excise duty and VAT, increasing the device cost. This tax suppresses domestic manufacturing of diagnostic equipment and the import-intensive economy it fosters continues to inflate healthcare costs in a country where only 30% of healthcare is publicly funded.

It has also led to a chicken-and-egg squabble between medical advocacy groups in the country. For example, ahead of the presentation of the Union Budget in 2010, the Department of Pharmaceuticals sought a cut in the customs duty to facilitate imports, while the Association of Indian Medical Devices Industry sought a hike to promote domestic innovation.

The report that claimed out-of-pocket expenses had pushed 60 million people below the poverty line also found that urban centres were the primary users of sophisticated medical equipment even as the per capita expenditure on medical technology in the country was a frugal $2 to $2.5.

2. Corruption and Inefficiency

A part of the problem is corruption and inefficiency. There is no national body to oversee the procurement and provision of generic medicine, which currently originates from local manufacturers known to operate their plants in unsanitary conditions. On April 7, the day Sun Pharma announced that it would fully acquire Ranbaxy Labs, Wockhardt publicly acknowledged that its plant in Aurangabad had been found to contain urine and mould in the vicinity of testing samples during an inspection by the US Food and Drug Administration.

All three companies now are disallowed from exporting certain drugs to the US and Europe. The reason they are allowed to release their drugs in the domestic market is because there is a demand for generic drugs and because there are about 1,500 health inspectors for more than 10,000 factories in the country, resulting in one in every 22 locally-produced samples being of substandard quality. In Tamil Nadu alone, 4,000 health inspector positions remained vacant in 2012.

Moreover, public healthcare professionals are not up to the mark. As the recent Chhattisgarh sterilisation camp tragedy illustrated, medical camps are often understaffed by ill-equipped doctors and technicians. One surgeon at the Chhattisgarh camp reportedly performed 83 tubectomies in six hours. In Odisha, cycle pumps were used to dilate the cervices of some women in a sterilisation camp.

Data from the Ministry for Health and Family Welfare shows that, since 2008, 700 people have died after going through government-sponsored sterilisation programmes.

3. Caste system

What exacerbates all these issues is the social setting their providers and users are situated in, and the caste system in that setting. On November 20, Arundhati Roy gave a lecture at the University College London, titled “The half-life of caste: The ill-health of a nation”. She started by saying, “We are still a society where a public health worker will refuse to touch children who are ill because they are untouchable. There are doctors who refuse to do a post-mortem because it’s polluting to touch” a dead body.

She argued in the lecture that the notions of purity and pollution that casteism enshrines, whose persistence M K Gandhi secured by institutionalising them during the freedom struggle, often deter good health practices, especially among poor women and children and those belonging to the lower castes. As the chart below shows, India’s infant and maternal mortality rates are worse than those of its neighbouring countries and BRICS nations.

1418035383-447_Mortality-rates-2013-IMR-MMR-chartbuilder

As the British medical journal The Lancet wrote in an editorial on November 29, “This ingrained inequality has led to tacit acceptance of the caste system, which has created, among other challenges, a preventable epidemic of mortality among women and children.” In effect, irrespective of what changes are instituted at the top, they will not reach the masses if access to healthcare and medical services remains segregated by caste.

These three hurdles are further compounded by successive governments’ tendencies to confusion. On one hand, Prime Minister Narendra Modi promises more All India Institute Of Medical Science in the country and on the other cuts the health budget by $900 million. The United Progressive Alliance government before him managed to eradicate polio but let that pursuit overshadow that of full-immunisation, the rate of which has fallen in developed states like Tamil Nadu, Maharashtra, Haryana and Punjab.

Such equivocal measures are the product of the thinking that health is purely a biological concern, not influenced by understaffed training institutions, overzealous eradication drives, import-friendly regulations, inexplicable shortage of health inspectors or segregation by caste.