As medical students, we find that details very often overwhelm us. The intricacies of the human body and disease are so complex that they demand complete devotion. People and diseases eventually become abstractions, reduced to diagrams and flowcharts in our textbooks. It is then that it becomes important to turn to people like Dr Binayak Sen, people who have straddled that gap between detail and context; people who help us look at the larger picture. We met Dr Binayak Sen in Mangalore and sat down to have a stimulating conversation.
Inequity is killing people on a grand scale
“Have you seen the WHO (World Health Organization) report on social determinants of health?” asked Dr Sen. “There was a committee set up by the WHO under the chairpersonship of Sir Michael Marmot which came to the conclusion that inequity is killing people on a grand scale. Inequity is that part of inequality that can be manipulated, can be decreased. If we look at the factors responsible for health or the absence of it, the biggest factor, it turns out, is inequity.” Referring to a study conducted in 2008, Dr Sen explained how the life expectancy of a slum in Glasgow was 54 years, while in India, where ordinary people have a much lower standard of living and no access to such good health services, had a higher life expectancy, at around 62 years. This was a real example to show that inequity is killing people according to him.
“Now, we move on to more specific indicators, for instance, malnutrition”, he said. “In India, roughly one quarter of children are born with low birth weight. It doubles by the time the children are 3-6 years old. Half of all deaths in under-5 age groups are caused by malnutrition or diseases easily prevented by attainable means, such as access to basic healthcare. This is a terrible situation. Adult malnutrition is also a very important part of the scenario. Thirty-six per cent of adults in India have a BMI (body mass index) below 18.5. If you look at tribal areas, this figure rises to 40 per cent among men and 49 per cent among women. WHO says that if any community has 40 per cent of its members with a BMI less than 18.5, then you can consider it a state of famine. This state of famine is persistent in our country, it’s not like we’re walking in and out of it.”
“If we look at specific diseases, like TB for example, a report in the Indian Journal of Communicable Diseases states that over a 10 year period, deaths due to tuberculosis have increased five fold. If we had a proper preventable and primary healthcare system, these deaths need not have occurred. On the one hand you have this situation where people are hungry, where their minimum healthcare needs are not met and children are dying because they have no access to healthcare; and on the other hand you have people who are among the richest people in the world; and then you have large sections of people whose condition has improved and who are materially very well off. So, in that kind of a situation where inequity is a major factor and is increasing, the health of the people is going to get worse. What is important to understand is that it’s not just poverty that’s killing people, its inequity and lack of social justice”.
“If we look at the fundamental rights under the constitution”, said Dr Sen, “when we look at the directive principles of state policy, you find that the constitution has a clear mandate that all state action must be directed towards the reduction of inequality. This is the specific analysis of healthcare that I am trying to put forward and many others are doing it with me. I was part of the steering committee for healthcare in the 12th Five Year Plan in the Planning Commission. We ratified the report of the high level expert group set up for the universalization of healthcare under the chairmanship of Prof Srinath Reddy. That committee made a clear recommendation that there should be universalization of healthcare and everybody should be given specified levels of care on cashless basis and the government expenditure on healthcare should go from one per cent of the GDP (gross domestic product) to three per cent.”
“Three per cent of the GDP is nothing; any country worth its salt that you can name or think of, has a much higher proportion of GDP devoted to healthcare. But Mr Montek Singh Ahluwalia (deputy chairman of the Planning Commission) says that we don’t have three per cent for healthcare and they are going to increase it to around 1.5 per cent. He says if the states want to spend more money, then they are welcome to do so. That’s a really cruel thing to say because everybody knows that the states have no surplus funds to spend on healthcare. The funds needed to be spent on universalization; the Planning Commission is unable to meet that requirement. It has the wherewithal to provide for tax breaks. Five per cent of our GDP goes into tax breaks, another five per cent goes to the top 50 corporates of the country but to go from one per cent to three per cent for healthcare, it is giving Mr Montek Singh Ahluwalia heartache.”
As we progress in our profession, we will have to ask ourselves at some point, what role our profession plays in the society. We will eventually realize that effective delivery of healthcare is hampered by larger socio-political problems. So, do we stick to the traditional brief of a doctor and say that fixing the system is someone else’s problem or do we take it upon ourselves to tackle the unjust status quo?
“It is a choice that you have to make and in making that choice I don’t want to prescribe anything,” said Dr Sen when confronted with this conundrum. “First we have to look at the overall scenario, and then everyone would like to see how they fit into it. I think that’s a better way to go about it. As thinking people, we have to follow some kind of logic in our analysis. We can’t just go on individual motivation as a personal choice. Inequity is the framework within which we have to look at people’s talents, people’s priorities and what you can contribute. I would say that it’s more important to think in terms of that. In this contention, of how you factor in the analysis of the health situation into your choices, you have to take sides. The system is not kept in place of its own volition; it is kept in place because people see an advantage in keeping it that way. So, you have to decide whether your contribution is going to correct this system or make it worse. You can’t stay neutral; you should not be in a situation where you think you are just going along. You have to be conscious as a thinking citizen, conscious of the choice you make and own up to it. That is the duty of the intelligent person towards his own conscience. You decide how you want to address this scenario. You have to think of your future and plan, but in planning, this scenario needs to be taken into account. Don’t make your choice in ignorance or in feigned ignorance. Don’t fool yourself that the choice you have made is a matter of convenience; it’s a moral choice you have exercised. Our constitution gives you the right to exercise it and you must take the responsibility for it.”
A Moral Anchor
The choice that Dr Sen has made is apparent. He graduated from CMC (Christian Medical College) Vellore, with an MD in Paediatrics. He then went on to join the Centre for Social Medicine and Community Health at the Jawaharlal Nehru University, New Delhi. He began his commitment to rural health programmes in Hoshangabad district of Madhya Pradesh, working in a community based rural health centre focusing on tuberculosis. He went onto working with mine workers in Dalli Rajhara. He succeeded in helping the workers set up a hospital of their own called Shaheed Hospital under the Chhattisgarh Mukti Morcha. Later, he moved to Raipur and was part of an advisory committee, which designed a community based health worker programme across the state called the ‘Mitanin programme’. He also ran a weekly clinic in a tribal community in Dhamtari district. Dr Sen and his wife, Dr Ilina Sen, then went on to create ‘Rupantar’, an NGO (non-governmental organization) which trains and monitors community health workers spread across 20 villages.
“I went into a rural area, a forest area where malaria was rampant. As I walked down the street, I would know the names of the people in each house who were suffering. Now this is the kind of situation, which need not exist. There, we set up a system in which health workers were taught to take malaria smears and examine them to make a diagnosis of malaria within 6-24 hours. Those with malaria were treated and pregnant women were given malaria prophylaxis. Now, as a result of the lowering of the parasite load, the whole area became free of malaria.”
While continuing to work with the tribal community, he transitioned into human rights activism, as an extension of his profession, seeking to ameliorate inequity just as he would ameliorate any other disease. He served as the general secretary of the state Peoples’ Union for Civil Liberties (PUCL) committee for five years and as vice president of the PUCL national committee for three years. It was in this capacity as an office bearer of the PUCL that he spoke out against the state government backed Salwa Judum’s human rights violations. He has paid a heavy price for this decision. At the time of our meeting, he was out on bail, having been convicted and sentenced to life imprisonment in 2010 by the Raipur sessions court, Chhattisgarh, for sedition and helping Naxalites to set up a network to fight the state. His conviction and subsequent imprisonment caused an international uproar, fuelling worldwide agitation. Forty Nobel Laureates, including Amartya Sen and Noam Chomsky, appealed for his release.
He also has several awards to his name, his social work being honoured across the globe.
Dr Sen would not want this article to be about him, his work or his travails for, in spite of being the hero that he is, he embodies the stereotypical humility that is so often seen in such people of resolve. When a visitor came up to him and mentioned how farcical his conviction under the sedition laws was, he replied with indignation: “I am not alone, there are thousands of people charged with sedition. There are children sitting on dharna in Kudankulam who have been charged with sedition!” The tragedy of the injustice he sees around him seems to consume him, causing him to speak about it with an obsessive passion. In an age where personal ambition almost always trumps the sense of civic duty, Dr Sen’s selflessness seems anachronistic. Such people of rectitude and conscience are our moral anchors. In our pervasive ocean of immorality, they provide a much-needed ethical mooring. They ought to be honoured by the society; their lives ought to be celebrated. The fact that instead of showering him with adulation, we besmear and imprison him is almost as tragic as the inequity he seeks to ameliorate.
The Choice Before Us
Whether we like it or not, our profession is enmeshed in the socio-political framework of our times. We tend to forget that a world exists outside of our textbook and our wards, a world of conflict, inequity and injustice. We may like to believe it does not concern us. Maybe, we choose to be blind to it and continue to live in our comfortable cocoons. Or maybe, just maybe, we let Dr Binayak Sen inspire us out of our indifference.
After all, it is all about making choices, about taking sides.
About two months ago, we had an opportunity to meet Dr Binayak Sen in Mangalore. We decided to take this opportunity to interview him for our annual college magazine. When we came across India Medical Times, we thought it would be a good idea to send the article to IMT as it would ensure a wider readership for our article. The article will appear in our college magazine in February next year.
Our interview with Dr Binayak Sen was possible solely due to the initiative taken by V Suresh, eminent lawyer, activist and national general secretary of the PUCL. We owe him our deepest gratitude.
Tishya Vepakomma and Sai Krishna Vadlamudi
2nd year MBBS
Kasturba Medical College, Manipal