Tuesday 13 August 2019

Lessons of Life from Adam Smith

Adam Smith is considered to be the father of liberal capitalism and free markets. His book "The Wealth of Nations" is considered as one of the most influential books on economics. Smith had written another book, "The Theory of Moral Sentiments", which is hardly remembered today, which was about human nature and how to live a fulfilling life. Russ Roberts' book "How Adam Smith can change your life" is a reflection and analysis of this lesser known book of Smith.
Adam Smith - Book by Russ Roberts - Bookcover


This post is about the book "How Adam Smith can change your life - An Unexpected Guide to Human Nature and Happiness". The book is full of interesting insights about human nature and why we behave the way we do. In this post I am going to focus on only 2 ideas of this book.

Self-Deception & Confirmation Bias

According to Smith, human beings are self-centred. For us our own life problems are much more important compared to big tragedies befalling humanity in some far away place.Human beings also have a big capacity for self-deception, sometimes unconsciously, so that we find an excuse to do things without listening to the voice of our self-conscience. Russ writes about this self-deception:

Rather than see ourselves as we truly are, we see ourselves as we would like to be. Self-deception can be more comforting than self-knowledge. We like to fool ourselves. 

When we behave in selfish and self-serving ways, sometimes we even justify it by saying that we did it for altruistic reasons, to help others. We describe our selfish actions in selfless language. According to Smith, we do this not only to convince others but also to convince ourselves, so that we can continue to hold a positive image of ourselves in our minds. According to Smith, our behaviour sometimes falls short of our ideals not because we’re bad people and not because our self-interest outweighs our benevolence, but because of what is called the "confirmation bias" - we don’t realize that we’re not living up to our ideals.

A modern name for Smith’s insights about self-deception is confirmation bias. Confirmation bias happens when we filter reality through our biases, ignoring evidence that challenges or refutes what we believe and eagerly accepting evidence that confirms what we believe. ... Another modern name for the challenge of understanding our complex world with any precision comes from Nassim Taleb—the narrative fallacy. We like narratives that follow a nice, clean pattern. Evidence that fits the narrative is noted after the fact. Other evidence that doesn’t fit the narrative is discarded.  
Among the persons offering advice motivated by self-interest and camouflaged as altruism, there are some examples of doctors, which brought to my mind many instances of distorted private medical services. For example, private nursing homes have much higher rates of Caesarean section instead of normal deliveries. Heart specialists in private hospitals advise much higher numbers of coronary artery bypass operations. I believe that this is a mechanism of self-deception, so that we doctors convince ourselves that we are not doing it for money but these operations are for benefiting those persons. However, this is not just about doctors, it is true for all kinds of professionals and private businesses. They don't see themselves as dishonest, many of them may be convinced that they do it to help others.

Everyday Actions Creating Civilization

The second idea from Smith that I want to touch in this post, is about small or minor actions by each of us, which taken alone are insignificant, but combined with similar actions of millions of other persons, together create the norms of our societies. Russ calls it this process, the "Emergent Order".

The economist Milton Friedman captured this strange paradox of small effects amounting to something significant when he said about supply and demand that the sum of negligible forces need not be negligible. So while my demand for apples has no impact on the price of apples, our demands all together, along with the decisions of suppliers, are what determine the price of apples. Not the greed of the grocer down the street, not my desire to get a good deal, but all our interactions together. And even though any one apple eater has no measurable or noticeable effect on the price, because she contributes an insignificant portion of the total demand for apples, apple eaters as a group have a very significant effect.Thus, Smith says that with our individual choices can lead to important social outcomes and this is how we create our society including our norms about morality, mutual trust and civilized behaviour.

This part of the book stimulated me to think about the kind of societies we are creating today. I think that when we choose our leaders and celebrities who behave in a certain way, they amplify the actions of their followers and thus determine the civilizational norms of our society. Through social media, such as Facebook and Twitter, these followers amplify their messages and gain strength from each other. The confirmation bias helps them to not see or listen to anything which does not fit in with their ideas. Thus, people with different ideas on the left and right of political spectrum, remain in their own circles and increasingly express themselves in ruthless and brutal terms, unable to see that they are mirror images of what they wish to fight.

At the same time, there is increasing acceptance of more extreme ideas. For example, when the news came about the sinking of a boat full of emigrants, some persons who are against emigrants, wrote on Twitter that it was good for feeding the fish. I think that this kind of thinking goes beyond being against emigrants - such ideas denote psychopath personalities. Thus, we creating societies where such expressions are acceptable, and persons can openly express such opinions without feeling ashamed about them. Across the world we have many political leaders, who encourage such ideas, sometimes using religions to justify them.

Conclusions

Adam Smith had written his book "The Theory of Moral Sentiments" in the mid-18th century and the original book is not so easy to read. Russ Roberts' book "How Adam Smith can change your life - An Unexpected Guide to Human Nature and Happiness" explains its ideas in an easier to understand manner. As you can see from my reflections above, these ideas from 18th century are still valid and have much to teach us. I think that Russ Robert's book is one of the more interesting books I have read recently.

*****
#adamsmith #russroberts #bookreview

Sunday 11 August 2019

From Disability Action Plan to Rehab 2030

In July 2019, the "Global Disability Action Plan (GDAP) 2014-2021" of the World Health Organisation (WHO) was replaced by the "Rehab 2030" plan. This post is about the key differences between GDAP and Rehab 2030 and also about my opinions regarding the new plan.
Community volunteers teaching parents about rehab in India - Image by S. Deepak

WHO is the health body of the United Nations (UN) and advises national governments on their health policies and programmes. Thus, Rehab 2030 is important because it will influence rehabilitation programmes and services in countries over the next decade.

Global Disability Action Plan (GDAP) 2014-21

The overall goal of the GDAP 2014-21 was "Better health for all persons with disabilities" and it had three objectives:

(1) To remove barriers and improve access to health services and programmes

(2) To strengthen and extend rehabilitation, habilitation, assistive technology, assistance and support services and community-based rehabilitation (CBR)

(3) To strengthen collection of relevant and internationally comparable data on disability and support research on disability and related services

The GDAP 2014-21 was supposed to reach these 3 objectives through human rights based approach, empowerment of persons with disabilities, life-course approach, culturally appropriate person-centred approach, multi-sectoral Community-Based Rehabilitation (CBR) and universal design.

Rehab 2030 Plan

The new plan has a wider view of the rehabilitation services by focusing on functionings which can be limited due to health conditions, environment and by the interaction between these two. It proposes to develop Packages of Rehabilitation Interventions (PRIs) for the following groups of functionings within the next 10 years:

(1) Musculo-skeletal:Low-back pain, neck-pain, fractures
Other injuries
Osteoarthritis, amputation, rheumatoid arthritis

(2) Neurological:Cerebral palsy, brain injury, Alzheimer-dementia, spinal cord injury, Parkinson's disease
Multiple sclerosis, motor neurone disease, Guillain-Barré

(3) Cardio-Vascular Diseases including myocardial infarction and heart failure

(4) Chronic respiratory diseases

(5) Neoplasms

(6) Mental disorders:Schizophrenia
Developmental and intellectual disabilities
Autism spectrum disorders

(7) Sensory Impairments:Hearing loss
Vision loss

Rehab 2030 aims to make these PRIs to be available as part of the Universal Health Coverage at different levels of the health services, as shown in the graphic below.
Rehab 2030 Plan of WHO

The lowest level of intervention is that occurring at home and in the community - informal and self-directed rehabilitation. Moving up from below, the other levels of rehabilitation interventions are primary health care, secondary & tertiary health care, community-delivered rehabilitation and specialized high intensity rehabilitation.

Changes from GDAP to Rehab 2030

From Impairments to health conditions: In many ways, the vision of Rehab 2030 is very different from that of GDAP. Till GDAP, the focus was on the effect of impairments. The focus of Rehab 2030 is on the impact of health conditions. This subtle shift, focusing on "health conditions" instead of "impairments caused by the health conditions" opens rehabilitation programmes to the needs of other groups of persons, such as elderly persons, and persons with cardiac and respiratory conditions.

Rehabilitation Interventions: The other significant change from the past is the focus on "rehabilitation interventions". During the late 1980s and early 1990s, the Disability & Rehabilitation team at WHO had decided to focus on the delivery of rehabilitation services at community and primary health care level, leaving aside the issues related to rehabilitation interventions at intermediate and higher levels. However, over the past 20 years, new technologies have introduced a better understanding of health conditions and raised opportunities for their treatment which were not available in the past. WHO needs to provide guidance about these interventions. For example, today some children born with deafness can have cochlear implants and grow up hearing. This change goes in that direction.

Outreach Services: Another significant change is the acknowledgement of a level of rehabilitation services, which was not mentioned in any WHO document over the past many years, the "community-delivered rehabilitation". During our visits to rehabilitation services in different countries, we often came across the rehabilitation staff visiting some peripheral or rural areas to provide rehabilitation in the communities. This was called "outreach rehabilitation services". I remember a few discussions in WHO about the undesirability of these outreach services - they were costly, and often did not have adequate staff. I think that by acknowledging the Outreach services, it accepts an existing reality instead of closing our eyes to it due to ideological beliefs.
A disabled child in a peripheral hospital, Mongolia - Image by S. Deepak

Downplaying CBR: The 4th significant change is that it downplays "community-based rehabilitation" (CBR). Instead of CBR, it calls it "informal and self-driven rehabilitation".

CBR did start as informal and self/family driven rehabilitation interventions in 1980s. However, in 1990s, other interventions related to education, livelihood, etc. were added to the CBR mix, which were not rehabilitation interventions. More recently, many organisations involved in CBR programmes have opted for the term "Community-based Inclusive Development" (CBID), which means that perhaps we can go back to using the term CBR only for the rehabilitation intervention activities at community level. Anyway, the new rehab plan rightly limits itself to the health services component of rehabilitation instead of mixing it with CBID and non-health sector interventions. 

Needs for defining community rehab interventions: I also hope that through the PRIs, Rehab 2030 will also look at defining of rehabilitation interventions for "informal and self-driven rehabilitation". During 1990s, WHO had played a crucial role in development of simple manuals on basic rehabilitation interventions, for example, for children with cerebral palsy and persons with spinal cord injury. Today, many countries have CBR as part of their national rehabilitation strategies. It will be useful for them to have updated information on evidence-based basic rehabilitation interventions for use at self-care and community level (though in part, internet is bringing better information, skills and technological support to the communities and families, who can also share their personal experiences with other communities).

Social Model and Rehab 2030

Rehab 2030 hardly ever uses the word "persons with disabilities", because it focuses on "functioning related to health conditions" instead of "impairments". However, persons with disabilities will be one of the biggest group of the users of the rehabilitation interventions and it will be difficult for WHO to not engage with them. The UN Convention on the Rights of Persons with Disabilities (CRPD) and the focus of Sustainable Development Goals on persons with disabilities, make it obligatory for WHO to engage with the DPOs/OPDs. For example, the UN Flagship report on disability which came out earlier this year (2019), also links with rehabilitation and assistive technology services.

During 1980s-90s, the Disabled Peoples' Organisations (DPOs or Organisations of Persons with Disabilities OPDs) came up with the "social model of disability", which was seen in contra-position to the "medical model of disability", implying that medical rehabilitation services were somehow bad or not useful. I personally believe that the two models are complementary - medical model focuses on individuals with impairments and social model, helps us to fight against the barriers created by the society. Both are needed. Rehabilitation interventions in the health services can not be organised through the social model - they are medical interventions and are carried out in line with the way medical/health services are organised.

Persons with stable impairments such as persons who are blind or deaf or those who had a disability in the childhood and are now grown-up, such as persons with cerebral palsy, often complain about "labelling" of their identities with their clinical diagnosis, which creates specific expectations and prejudices among people. However, rehabilitation services cannot provide treatment without a diagnosis. Such issues will continue to be a cause of friction between persons battling for superiority of social model over the medical model of disability. However, persons with disabling progressive health conditions understand the complementarity of the two models of disability in their lives much better.

Final Comments

The famous Alma Ata conference on primary health care (PHC) held in 1977 had proposed "preventive, promotive, curative and rehabilitative care" at the community level. However, in practice, citing lack of resources, PHC was limited to certain key interventions, which had excluded rehabilitation services.

During the 1990s, repeated attempts to promote inclusion of rehabilitation services in PHC had yielded little or no results. Only during the past 10-15 years, some countries have adopted the CBR approach and a few of them have linked it with their PHC services.

Today, in most countries we have persons with disabilities and DPOs/OPDs who are strong advocates for their rights while countries have signed and ratified CRPD. New national disability policies and programmes related to SDGs may also be offering opportunities for promoting rehab services in countries, which were not there in the past.
A disabled child with a CBR volunteer, Guyana - Image by S. Deepak

The increase in ageing populations and chronic life-style conditions, have made it imperative for people to play a greater role in their self-care, while using hospitals and specialized services for acute care and complications. New technologies including internet and mobile phones are playing a role in people's access to information. Rehab 2030 will need to facilitate this transition.

By focusing on funtionings, hopefully the new rehabilitation plan will help us to think of rehabilitation needs in a holistic way.

*****
#rehab2030 #rehabilitationneeds #who_rehab #cbr #personswithdisabilities

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