Global Health Updates

A Luxury Called Health: A Doctor's Journey Through the Art, the Science and the Trickery of Medicine

?A Book by?Kavery Nambisan

About the Author. Kavery Nambisan was born in Kodagu district, Karnataka. She has worked predominantly in the rural parts of Uttar Pradesh, Bihar, Tamil Nadu and Karnataka, and was a governing council member of the Association of Rural Surgeons of India. Kavery was married to the poet and writer Vijay Nambisan. She lives and works in Kodagu district. Publisher : ?Speaking Tiger Books, New Delhi 110049, India

?BOOK REVIEW by Chitra Ahanthem

?Kavery Nambisan's account of healthcare in India reveals bitter truths but also beacons of hope 'A Luxury Called Health', written by a doctor who is also a novelist, needs to be not only read but also discussed.

Kavery Nambisan's account of healthcare in India reveals bitter truths but also beacons of hope. What do you get as a reader when a writer of fiction, and a surgeon who has worked closely in both the public and private health sector, picks up her pen to write on the state of the health system in the country?

The answer is easy: you get a book that lays bare the fact that the health of the citizens of a nation is an investment, that the health system is a part of nation building and effective governance and that it is time to learn from mistakes that have been made and continue to be made.

You get a book that comes from years of working amidst the dust and the grime of government health care set-ups, from having observed the profit-oriented approach of the private sector. A book that offers quiet hope that things can, and must, improve.

What's wrong... Kavery Nambisan's first work of non fiction, A Luxury Called Health: A Doctor's Journey Through the Art, the Science and the Trickery of Medicine, is exactly what its title says, with little drama or exaggeration. It is an honest examination of this thing called healthcare, of the systems that are working and not working, of the people who are its faces and, at times, because of whom, healthcare turns into what it should be: effective, affordable and something that everyone can trust.

A passage from Fyodor Dostoevsky's The Brothers Karamazov, where a doctor examines a terminally ill patient in a very poor home, that features in the introduction is an apt reminder of what happens when the poor try to access healthcare: the hope and despair felt by the patient's loved ones and the disdain that the doctor projects. It sets the tone for what follows in the subsequent chapters.

Later, Nambisan conveys how patients and their families often put doctors and healthcare staff on the pedestal of demigods and do not try to find out about the nitty gritty of how illnesses are treated. This makes them resort to threats and abuse when things do not go as they should.

?From the early traditional medical practices to the first steps taken in India to institute a medical institution to train and educate health-workers and medical staff, the author puts the focus on how the poor health of individuals affects the overall well-being of a nation. She takes readers into the time the seeds of a new nation were being sown and, along with them, the hopes and aspirations that went to building the health care system. It was a task made more difficult by entrenched caste practices, such as those of not even touching corpses, leave alone dissecting them as medical students.

?Nambisan's note of appreciation for the first wave coming from Kerala when it was still a profession that had few takers soon after Independence is a reminder of how far the health care system has come. But, as she shows with anecdotes and analysis, with this has come disparities between the public and the private sphere when it comes to health.

?... And what's right. What works for this book is that it stays clear of rhetoric or the blame game. Instead, it injects humaneness through personal insights while making a point on how the health system is interconnected to nutrition, poverty, hygiene, water, and sanitation. Nambisan makes the point that urban development ends with more buildings but little attention to, among other things, waste and rainwater management and water resources, which in turn, affects the health system. She emphasises that treating medical situations on a case by case basis, without a holistic strategy for improving health, leads to little progress.

?Thankfully, none of these heavy-duty issues weigh down the book and for that we have the quality of her writing to be thankful to. Perhaps only a writer of fiction used to the economy of words would have been able to cover such complex matters in a little over 300 pages. There are no appendices with tables and data, for the author speaks from her own long years of practice, with quiet, unwavering authority.

?The use of anecdotes from the history of medical practices across the world and in India, peppered with the author's own experiences, makes the book come alive in a way that is informative as well as thought-provoking. In one chapter that details the list of medical procedures in a health set-up, Nambisan admits how easy it is to treat patients as mere technicalities, and that it takes a lot to probe further or ask questions of a supervisor or senior colleague.

?There is little of handwringing or giving into hopelessness, even when the book details corruption and political apathy, as well as greed. In a chapter titled "Doctoring Reality", the author highlights rural initiatives started by medical practitioners who have given up lucrative placements to set up affordable and accessible services. It makes you wonder why we don't see many of these inspiring stories in the mainstream media.

?Towards the end the author takes readers into her personal space, as a spouse having to play part- bystander and caregiver when her husband, the acclaimed poet Vijay Nambisan, is diagnosed with cancer.

?Kavery Nambisa's voice is gentle but firm, with words of caution about how critical it is to listen to the voices on the ground, the doctors who work in remote areas with poor resources. For they are the ones whose intervention saves lives, instead of following protocols laid down by international organisations like the WHO, especially in the wake of the Covid-19 pandemic.

?A Luxury Called Health is an important book, one that needs to be read and discussed. It exposes the failings of the medical system in the country over the years, but it also shines a light on the people who mend worn-out bodies and organs, bringing hope and succour.

?Chitra Ahanthem is former editor of Imphal Free Press, a newspaper published in Manipur. She is also a Manipuri-to-English translator.

?https://scroll.in/article/1013132/kavery-nambisans-account-of-healthcare-in-india-reveals-bitter-truths-but-also-beacons-of-hope

Abortion Pills by Mail

??Lifting the restrictions on mifepristone would make medication abortion more accessible, but in 19 states that have already banned telemedicine visits for abortion pills, women would probably need to travel to states that allow it

?The US federal government permanently lifted a major restriction on access to abortion pills. It will allow patients to receive the medication by mail instead of requiring them to obtain the pills in person from specially certified health providers.

?The decision, by the US Food and Drug Administration, comes as the Supreme Court is considering whether to roll back abortion rights or even overturn its landmark 1973 decision in Roe v. Wade that made abortion legal nationwide.

?The US F.D.A.’s action means that medication abortion, an increasingly common method authorized in the United States for pregnancies up to 10 weeks’ gestation, will become more available to women who find it difficult to travel to an abortion provider or prefer to terminate a pregnancy in their homes. It allows patients to have a telemedicine appointment with a provider who can prescribe abortion pills and send them to the patient by mail.

?Earlier this year, for the duration of the pandemic, the F.D.A. temporarily lifted the in-person requirement on mifepristone, the first of two drugs used to end a pregnancy. The decision to make this change permanent is likely to deepen the already polarizing divisions between conservative and liberal states on abortion. In 19 states, mostly in the South and the Midwest, telemedicine visits for medication abortion are banned, and these and other conservative states can be expected to pass other laws to further curtail access to abortion pills.

?Yet other states, like California and New York, which have taken steps in recent years to further solidify access to abortion, are expected to increase the availability of the method and provide opportunities for women in states with restrictions to obtain abortion pills by traveling to a state that allows them.

?“It’s really significant,” said Mary Ziegler, a law professor at Florida State University. “Telehealth abortions are much easier for both providers and patients, and even in states that want to do it, there have been limits on how available it is.”

?“The Biden administration today moved to weaken longstanding federal safety regulations against mail-order abortion drugs designed to protect women from serious health risks and potential abuse,” said a statement from the group Susan B. Anthony List. “The Biden administration policy allows for dangerous at-home, do-it-yourself abortions without necessary medical oversight.”

?The F.D.A. did not issue a formal statement on Thursday, but it updated a web page to reflect the decision and sent letters about the change to the two companies that make mifepristone and to medical groups that had sued over the requirement.

?“The agency conducted a comprehensive review of the published literature, relevant safety and adverse event data, and information provided by advocacy groups, individuals and the applicants to reach this decision,” an F.D.A. spokeswoman said.

?The F.D.A. did not ease two other elements of its restrictions on mifepristone, which fall under a program called Risk Evaluation and Mitigation Strategy. One restriction requires patients to sign an agreement acknowledging that their provider has informed them about the drug. The other requires it to be prescribed by a specially certified health provider.

?“F.D.A. has determined that certain restrictions continue to be necessary to ensure the safe use of the drug,” the spokeswoman said.

?The agency did say Thursday that pharmacies could begin dispensing mifepristone if they became certified by the drug’s manufacturers and if they received the prescription from a certified health provider. Reproductive health experts said they expected further details about pharmacies’ role to be worked out in the coming weeks.

?So far this year, presumably in anticipation of such a decision, six states banned the mailing of pills, seven states passed laws requiring pills to be obtained in person from a provider, and four states passed laws to set the limit on medication abortion at earlier than 10 weeks’ gestation, said Elizabeth Nash, the interim associate director of state issues for the Guttmacher Institute, a research organization that supports abortion rights.

?Susan B. Anthony List said in its statement that next year, at least seven additional states were likely to enact laws restricting the method.

?The current practice is that women who live in states that don’t allow telemedicine for abortion must travel to a state that does — although they don’t have to visit a clinic. They may be in any location within that state for their telehealth visit, even a car, and may receive the pills at any address in the state.

?But legal experts said they expected supporters of abortion rights to try to find ways to make the pills available without requiring a patient to travel, including possibly filing legal challenges to state laws banning telemedicine for abortion.

?“There’s going to be plenty of people who try to use them in states where they’re illegal without traveling out of state, legal ramifications aside,” said Professor Ziegler. She said such efforts might include clearinghouses that would try to allow “fudging where people’s addresses are to receive it” and a “black market” that might emerge.

?In data released last month by the Centers for Disease Control and Prevention, 42 percent of all abortions — and 54 percent of abortions before 10 weeks — occurred with medication in 2019, the most recent year for which C.D.C. data is available. (The report represents most of the country, but does not include data from California, Maryland and New Hampshire.)

?In 2020, in some states, including Indiana, Kansas and Minnesota, the method accounted for a majority of abortions, according to state health department reports.

?The C.D.C. also reported that 79 percent of all abortions occurred before 10 weeks’ gestation, suggesting that there are many more women who might choose abortion pills over an in-clinic procedure if they could.

?Mifepristone was approved in the United States in 2000. The F.D.A. imposed restrictions on the drug, which blocks progesterone, a hormone necessary for pregnancy to develop. The rules allowed patients to take mifepristone in their homes or anywhere they chose once they got it from the certified provider, making it the only drug that the agency required to be obtained in person from a medical provider but that did not need to be taken in the presence of a provider, medical experts say.

?The second medication, misoprostol, which causes contractions similar to a miscarriage and is taken up to 48 hours later, has long been available with a typical prescription.

?Mainstream medical organizations and abortion rights groups have long urged the government to ease restrictions on mifepristone, citing data indicating that mifepristone is effective and safe, including when dispensed by mail.

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?Decolonising global health a Roadmap

?Khan M, Abimbola S, Aloudat T, et alDecolonising global health in 2021: a roadmap to move from rhetoric to reformBMJ Global Health 2021;6:e005604.

?Decolonising global health was a hot topic in 2020. It was the subject of more than 50 academic articles between January and December 2020, appeared as a new area covered in numerous conferences, and featured in public statements by leaders of global health organisations

?‘Decolonising global health’ as a movement that fights against ingrained systems of dominance and power in the work to improve the health of populations,

?“Global health has evolved from colonial and tropical medicine, which were ‘designed to control colonised populations and make political and economic exploitation by European and North American powers easier’. The operations of many organisations active in global health thus perpetuate the very power imbalances they claim to rectify, through colonial and extractive attitudes, and policies and practices that concentrate resources, expertise, data and branding within high-income country (HIC) institutions

https://gh.bmj.com/content/6/3/e005604