Importance of Alternative Medicine

Over the past couple of years, ever since we have broadband internet with unlimited use, I often watch some YouTube video channels including lessons on cooking and about the use of specific software. I also like some channels on politics, health related issues, Indian classical music and dances.

One of health related channels which I often watch is Medlife Crisis by Dr Rohin Francis from UK. Recently, I came across one of his older videos, which was about "alternative medicine". In this video he had explained about the importance of evidence-based medicine and how this scientific approach ensures that we can truly understand the efficacy of treatments and make rational choices about medicines. The other aspect of his intervention was that alternative medicine lacks this evidence-based approach and thus for him it was mostly hogwash.

In his intro on this channel he also says that "There's a lot of bad science on YouTube, especially medicine, with quacks and clowns peddling garbage", which probably also refers to alternative medicine, apart from other conspiracy theorists and No-Vax groups. The image below shows a person receiving a traditional treatment in Mongolia.

In another tiny video titled "How does Homeopathy work?", he has a short no-nonsense answer to this question - "It doesn't".

Rohin Francis is not the only one who speaks out against wasting money on alternative medicine. Some of my other doctor friends have been very active against quacks and untrained persons masquerading as doctors in India. Some doctors on Twitter regularly rant against homeopathy and alternative medicine practitioners.

I understand from where all these persons are coming from. However, I do not agree with them that alternative medicine is all about non-evidence based quackery. In this post I want to share some personal experiences and some opinions regarding the role of alternative medicine in today's world.

Disclaimer: Quacks & Clowns Peddling Garbage

I know that there are persons who claim to have miracle-powers and who can cure all kinds of conditions. They prey on people when they are most vulnerable and psychologically fragile and they do it to earn money and gain power. Some of these frauds may be mentally ill and may actually believe in their supernatural powers. This post is not about justifying any of them. They do need care and treatment for their delusions and if needed, deserve law-suits and prisons.

I also do not wish to say that alternative medicine can cure everything such as conditions like high blood pressure or diabetes or cancer. People who give up their blood pressure or diabetes medicines because of their beliefs in alternative medicine, often end up with irreversible body damage to their vital organs like kidneys or eyes. Conventional (western) medicine is a better choice for most such persons.

Origins of Alternative Medicine

For thousands of years, ancient humans have tried looking for treatments for common health conditions. They did it mainly by looking for plant-based treatments. The plant-based medicines they identified, did not have the backing of double-blind studies on random samples of carefully chosen groups, but to call those "non-evidence based" would be a bit of stretch. Many of our common modern medicines from Aspirin to Quinine and Artemisia come from those traditional experiences. Guys looking for the next blockbuster drugs have often stolen the knowledge of plants and herbs from traditional healers. Scientists carry out experiments with synthetic derivatives based on those same plants and herbs and then do scientific trials to show their effectiveness. Many of them call as quacks the traditional healers in villages who are using those same herbs, simply because they base their knowledge on the oral transmission of experiences and tradional learning.

In countries like India, China and Mongolia, people practicing traditional medicine, study in their medical collages just like students studying modern medicine. For example, in Ayurvedic medical collages in India (I have visited 2 of them), students study for their medical degree for 6 years and their curriculum includes all the subjects such as anatomy, physiology, pathology and pharmacology, taught in conventional medical colleges.

However, a part of their studies is based on beliefs which modern science does not accept. For example - the Chinese beliefs about meridians running through the body with the energy points and the balancing of Yin and Yang forces; or the Indian beliefs about the three body humours (vayu, kaffa and pitta); or the homeopathy belief about using "like to counter like" and the power of dilutions of medicines. These beliefs do not fit with the understanding of modern science, because they do not follow the logical-thinking paradigm but follow some other esoteric or intuitive paradigms.

Shaping of Our Beliefs - Personal Experiences

Our beliefs are predominantly shaped by our own life experiences. Scientists say that our experiences are anecdotal evidence and are unreliable and usually biased. So we should only believe in what scientists and experts tell us. However, from personal experience I know that if I have experienced something, I may accept scientific opinions but I will also find a way to keep my own opinion based on my experience, even when the two are contradictory. This seems to be a common human trait.

Let me share a few experiences regarding alternative medicine, which have shaped my ideas on this theme.

My first experience with alternative medicine was with homeopathy in 1980s, when I was a community doctor. I had developed a strong pain in my left shoulder and had difficulty in lifting that arm. For many days I had taken anti-inflammatory and pain-killer medicines. In those days my paternal aunt had high blood pressure and I often visited her house for her check-ups. My aunt's husband, my uncle, had retired and taken up homeopathy as a hobby. He gave free homeopathic medicine to anyone who came to him. During one visit, after checking my aunt's blood pressure, I told my uncle about my shoulder pain and that I was tired of taking pain-killers as they were giving me gastric problems. He asked me numerous questions about the pain and then gave me a small dose of small sweet-tasting pills. He also wrapped in an old newspaper, two more doses of those pills and told me to take them after some hours. In less than 15 minutes after the first dose, my shoulder pain had disappeared and I had no difficulty in raising my arm. It was like a miracle and it changed completely how I felt about homeopathy.

My second experience of alternative medicine was more recent. In 2015, while living in Guwahati in India, I developed a severe knee pain. It became so bad that it curtailed my walking. I stopped going out for walks and took frequent anti-inflammatory and pain-killing tablets. In 2016, back in Italy, I went to an orthopaedic specialist for a few visits. A scan of my knees showed myxoid degeneration of Cruciate ligaments. I was given Hyaluronic acid injections in my knees, wore knee supports and took pain-killers. But nothing seemed to help me. After a few visits, the orthopaedic specialist told me that I had to learn to live with the pain as I was too young for knee replacement surgery. I was also told to reduce weight and do physiotherapy. I shared my scan results with an orthopaedist friend in USA and even his opinion was the same. Talking about it with a Catholic priest, who had become my friend in Guwahati, he suggested that I should try Ayruvedic treatment in a hospital in Kerala.

In January 2017, I went to the Ayurvedic hospital suggested by my friend for a one week of treatment. The treatment consisted of daily massages with oils containing different herbs. After a week's treatment, I was advised to rest for a few days. After that one week of treatment, my knees improved greatly and I could again walk without pain. I went back to that hospital for a week in 2018 and 2019. However, in 2020 and 2021, because of Covid-19, I have not been able to go there and lately, I have again started to have some knee-pain after walking for a few kilometres, though the situation is yet not as bad as it was in 2015. I am hoping to go back for this treatment later in 2022. The image below from 2019 shows Dr Vijayan, the chief Ayurvedic doctor of this hospital, together with his 3 students from the Ayurvedic Medical College who were doing internship with him.

A couple of years ago, I had talked to an orthopaedist friend to explain what had happened, to try to understand why I had responded to the Ayurvedic treatment. His answer was that it was possibly a placebo effect. According to him, another possibility was that the effect of medicines taken in Italy had arrived after a few months.

Perhaps it was indeed a placebo effect, but I would like to know why I didn't have this placebo effect after treatment in Italy and after the injections in my knees? Are traditional treatments likely to induce more placebo effects? If yes, why?

Finally, a friend from Mongolia told me about her experience with traditional Mongolian traditional medicine. We are working together for a project and communicate frequently. Last week she told me that her mother was very unwell due to Biliary colic caused by stones in her gall-bladder. Her mother is quite old and she was in a great deal of pain. However my friend was hesitating to take her to hospital due to Covid-19 fears, so she was visited at home by a doctor and was given pain-killers. He had suggested that if the pain would not pass, they might need to do surgery for removing the gall stones. After 3 days of injections, her conditions had continued to be serious, so the family invited a traditional healer to visit her. The traditional doctor visited her and wrote some herbal medicines. Due to Covid-19 restrictions, it was not easy to buy the traditional medicines but somehow they managed. That night, after taking the herbal medicine her mother slept well after many days of pain. The morning after, it was the day of Lunar new year, she woke up completely pain free - she got up from bed as if she had not been seriously ill till the previous evening. My friend who had been so worried was overjoyed. She said that it was like a miracle. Once again, I am sure that if we ask, most doctors in the hospital will explain it as placebo effect or some kind of psychological effect.

These are all anecdotal stories without any scientific value, they do not prove anything. But if any of these had happened to you, will you be able to forget them? Such experiences illustrate why so many persons, especially in traditional and rural societies, continue to go to traditional healers even when experts tell us that there is no proof regarding their usefulness.

For persons like me, strongly anchored in the Western Medical Paradigm, alternative medicine may not be the first line of treatment for any problem, but I will seek it if modern medicine are not able to resolve my health condition.

A Role for Traditional Medicine

Even for persons who feel that alternative medicine is not effective or is illogical, I feel that in today's world there are some functions for which it can be very suitable. For example, think of illnesses like flu and viral fevers. Doctors say that these should be given only some symptomatic treatment and not treated with antibiotics because they are not useful. Still a large number of people take antibiotics for such conditions. I think that taking alternative medicines for such illnesses is a good strategy to discourage the antibiotic abuse.

There are so many chronic non-infective conditions accompanied by pain, like the ones I had in my knees or in my shoulder, where long-term treatment with conventional medicines can have many side-effects. So if persons can feel better with alternative medicines, why not encourage them to try?

When modern medicines can do little because we have not found treatments for some conditions, I feel that people should be given the option of trying alternative medicines. The image below shows a modern pharmacy plant for making Ayurvedic medicines based on herbs and oils in India.

I know the situation in India - alternative medicine is usually cheaper and is much more accessible to persons. Unless it is a life-threatening condition, often alternative medicine can provide psychological support and even serve as placebo and reduce suffering. In many villages, traditional medicine is all they have because modern medicine is costlier and located far away.

I feel that demonising alternative medicine as fraud and quackery and to think of people preferring it as gullible or stupid, is not the right approach towards it.

(An earlier version of this post was first published on my blog in 2021)

Schio’s Old Water Canal

The north Italian town called Schio, where I live, has a one thousand-years' old water-canal. It starts from Leogra river and ends in another river called Timonchio. On its way it passes through different suburbs to the north and south of Schio, going underground for a brief part in the city centre. It is called Roggia Maestra (Master Canal).

Over the centuries, this canal has played a key role in the city’s life and history. Today, it has lost its importance for the city’s industries, however it accompanies some of the most beautiful walking areas around the city and continues to be important for the farmers.

I am always interested in discovering the history of old places. This post is a result of my search for information about this canal. I had found some information on internet, but most of it came from some books in the Schio library. There are some bits of information which are still missing.

The River-Crossing Canal

Schio’s water canal has one peculiarity, which I think is rare among the water-canals – it comes out from one side of the river, after a few kilometres it crosses over the river in a tube-bridge and then continues on the other side of the river. Have anyone heard of any such river-crossing canal in another part of the world? Do share information in the comments below.

Originally there were two water canals on the river Leogra. One was built on its western bank along the little town of Pieve Belvicino, a few kilometres to the north of Schio and it ended in a place called Ponte Canale (canal bridge), which had a wood-bridge for crossing the river. This was the old canal built around 1000 AD. The image below shows this part of the canal.

The second canal one was located along the eastern bank of the river, starting near Poleo area at the northern edge of Schio. It was much longer, it proceeded to the south of Schio towards a suburb called Giavenale where it accompanied the river Timonchio for a distance and then joined it. This canal was probably built later (after 12th century) though I could not find specific details about its construction.

During the second half of the 19th century, when the industrialist Alessandro Rossi was setting up his wool factory in Schio, he decided to combine the two canals by building a tube bridge because there was not enough water in the second canal.

Thus, the western branch of the canal in Pieve was deviated and connected through a tube bridge to the eastern canal. (The image below shows the starting of the tube-bridge where the canal from Pieve crosses over the other side).

On the other side, ruins of an old sawmill covered with vegetation marks hide the exit of the tube-bridge. At this point some water-basins and closes are also located, so that at times of high water levels the excess water can be diverted back to the river. (In the image below, water coming out of the tube-bridge on the eastern side).

Northern Part of the Canal in Pieve Belvicino

“Pieve” was the first important urban settlement of the Schio area. It had come up during the first millennium on the western bank of Leogra. It was connected to the settlements of Magre, San Vito, Malo and Vicenza on the south through a Roman road. It had the mother-church, an old fort and a tower. The people living on the mountains around it, came down here to sell their wool and dairy products. It still has an area called Valle dei Mercanti (Valley of the merchants) from those early days. At that time, Schio was a little settlement, cut off from the Roman road by the Leogra river. (The image below shows the Pieve part of the canal)

The Republic of Venice (Serenissima) and the Holy Roman empires (from Charles the Great to Fredrick Redbeard) competed for power in this area. In the 11th century, it belonged to the Malatraversi family, the Counts of Vicenza. At that time, the old St. Mary church of Pieve was the principal church of this whole area. The first water canal of Pieve probably pre-dates this period. It still passes next to that old church, though it seems that its specific course was changed over the centuries. It provided hydraulic energy through the use of water-wheels for setting up flour mills and wood-sawing mills. It also provided water for agricultural use.

Building the canal must have needed a lot of money – who had paid for it? The church or the Malatraversi family? There are no clear answers to this question, though it seems likely that the costs were covered by the noble family.

Schio's development had suffered as it was located between two rivers, Leogra on the east and Timonchio on the west. It only had small foot-bridges over the two rivers. Probably a carriage-bridge on Timonchio was built in 14t-15th centuries, which allowed it to be connected to Thiene and Vicenza. Thus, In late 15th century, a new cathedral was built in Schio while Pieve lost some of its importance.  The arch-priest also shifted from the old St Mary church of Pieve to the new Duomo church of Schio.

The area had many flour mills and weavers, which used the force of the water-torrents coming down from the mountains. In 18th century, the "Council of 150" approved the production of "Panni Alti" (fine clothes) in the valleys around Schio, so this activity increased. In the 19th century, wool mills arrived in the city.

Among the wool factories set-up in Schio, there was the factory of Francesco Rossi. His son, Alessandro Rossi, took over the factory management in 1849 and slowly became the biggest wool producer. (In the image above the abandoned Rossi wool factory in Pieve, which once had its own rail line). 

Pieve regained some of its importance in 1870s when a Rossi wool factory was opened there along the old canal. Electricity had not yet arrived and thus wool-factories used the water-power to run their machines. However, by the end of the 19th century, gradually steam and hydro-electric powers had replaced the simple hydraulic power of the water-flow and thus the canal slowly lost its importance for the wool factories.

The Canal in Schio’s Centre

The water-canal in Schio was built in the 12th centuy CE. Most of the early churches of Schio including the Duomo came up two centuries later along its western bank. The Schio part of the canal starts in the northern end of the city where the Gogna torrent coming down from San Martino merges with Leogra river.

Soon after it enters the old Cazzola wool mill, which was converted into a war hospital during the First World War, where a young Ernest Hemmingway had worked for a few months as an ambulance driver. (In the image below, the old Cazzola mill, where my mother-in-law also used to work)

The canal then proceeds towards the Rossi and Conte wool mills, which were also built along its western bank, near the city centre. Building of the big wool mills brought immigrants from surrounding countryside to Schio. My wife's grand-father had also arrived in Schio to work in the Rossi wool-mill around the end of 19th century. Thus, in late 19th and early 20th century, new houses were built and the urbanisation of Schio increased. New housing areas for the mill-workers were built on the agricultural lands on the eastern bank of the canal. Thus, new bridges were also built in the city and some parts of the canal in the city centre were covered and it became underground. (The image below shows the canal under the old Conte wool mill).

Some of the old names of city areas are the only memory of those early days of urbanisation along the canal. For example, Via Pasini, the main street in the centre of Schio today, was once called Via Oltreponte (Beyond the Bridge street) as it had a bridge over the canal - this part of the canal was later covered and today many persons passing from there are not aware of the waters passing underneath the street. 

Towards the end of 20th century, with the advent of a new phase of the globalisation, the wool factories of Schio gradually lost their markets and closed one after another. With urbanisation of the past 2 centuries, most of the agricultural use of the canal water had also decreased. Thus, the water-canal has lost some of its importance.

The last part of the canal located in the city centre of Schio still has the old “lavanderia”, the community washing space, where a wooden sculpture of a washer-woman remembers those days when women used to gather here to wash clothes.

Southern Part of the Canal

After passing through the Schio city centre, the canal comes out near Via Paraibo and proceeds to the rural part of the periphery along Via Mollette. The old ruins of the Cavedon sawmill are located here. The last tract of Via Mollette running along the canal has been converted into a beautiful walking/cycling area (in the image below).

From here, the canal comes closer to Timonchio torrent and runs alongside it to the area known as Giavenale-Maglio. Another new cycling and walking path has been created along this part of the canal. (The canal in Giavenale in the image below)

A few kilometres down this walking/cycling path, finally the water-canal ends in Timonchio. The image below shows the last part of the canal along the cycling-walking path).

Conclusions

Today the economic and industrial importance of the old water-canal of Schio has decreased, yet it has become important in other ways. Evolution has taught human beings about the importance of water. Schio and its surroundings are full of beautiful walking and cycling areas that are located next to its two rivers, Leogra and Timonchio, and its water-canal. It also continues to supply water for agricultural use.

Perhaps one day the cycle of the history will turn once again and the water-canal of Schio will restart play an important role in the city’s economic life. Till then, the aesthetic pleasure of its beauty and its importance for the nature are its contribution to the city life.

Researching the history of the canal and exploring its passage through the city was a rewarding exercise. It made me aware of how our landscapes change along the passage of time and events. For thousands of years, this landscape was only changed by the nature, but over the last few centuries, humans have accelerated the pace and scope of this change. Schio and its surroundings are beautiful and I am glad that the city could use some of those changes to improve its beauty through the old canal.

(An older version of the post was first written in June 2021 in my blog)

Failures in Global Health?

Three years ago, in July 2019 Dr. Madhukar Pai, Associate Director, McGill International TB Centre in Canada wrote an article on "Failures of Global Health". In this article he had written:

In global health, we love to talk about success stories and publish interventions that seem to work. Eradication of smallpox, dramatic decline in polio incidence, reduction in child mortality, etc. But we also know global health deals with huge, complex, challenges. And involves several agencies and stakeholders with their own agendas and political instruments. So, failure is guaranteed. Failure is a powerful tool for learning, and we can always learn from failed interventions and projects.

Then Pai went on to list some of the major failures in Global Health: "I do not see a similar openness about failure in the global health arena. To be sure they are discussed in hushed tones in the corridors of global health agencies in Geneva, New York and Seattle, but not quite publicly, in a way that facilitates learning."

I think that Pai was a little superficial for at least 2 of the failures (leprosy elimination in India and the goal of health for all) on his list. I feel that it is simplistic to give summary judgements of success or failure without taking the time to go and study what had really happened and the documents from that period. IMO, such views could have been understandable in past but in the internet age, so much information is openly available, such a judgement from Pai is less defensible.

Background

During the 1990s and 2000s, I was active in the discussions about Global Health at international level, for example, in the People's Health Movement (PHM). In that period, I was collaborating regularly with the World Health Organisation (WHO) in Geneva. Around 2004-05, for a couple of years I was also the president of ILEP, the international federation of organisations fighting leprosy. Thus, I witnessed firsthand most of the things about "Health for All" and "Eliminartion of Leprosy", I am writing about in this post.

The Failure of Leprosy Elimination in India?

Point number 9 on Pai's list of Global Health failures is about leprosy control in India. He says that it was a failure because, "In 2005, India declared leprosy to be eliminated and scaled-back on its leprosy programmes. Today, according to WHO, India harbors 60 percent of the world’s cases, with more than 100,000 new diagnoses each year." He links his judgement on this point to an article from New York Times, "In India, a Renewed Fight Against Leprosy - Health workers thought they had vanquished the disease in 2005. But it lived on, cloaked in stigma and medical mystery."

I believe that this is an unjust and superficial judgement about the leprosy services in India and its achievements. The "failure" in this case, if we can call it that, should be attributed to the World Health Organisation (WHO), which had set up the "Leprosy Elimination Goal - to reduce the prevalence of leprosy to less than 1 per 10,000 population by the year 2000".

The WHO goal was actually for "reducing the leprosy burden" but it was called "elimination goal" for political reasons. In 2000, WHO had declared that the elimination goal had been reached at the global level, but India was not included as a success at that time. India had managed to reduce its leprosy burden to the level of WHO's elimination goal only in 2005.

Declaration of "Global Leprosy Elimination" did lead to premature closure of many leprosy programmes around the world, but fortunately not in India.

Instead of asking about the "failure of India's leprosy programme", we should be asking - "What is the impact of setting international disease-control targets and what can we learn from the experience of WHO's Leprosy elimination goal?" I want to answer that question in this post.

I am writing this post from my memory of the events, but a lot has already been written about it, as can be seen from a simple literature search.

WHO's Leprosy Elimination Goal

The goal of "Eliminating leprosy as a public health problem by the year 2000" was decided by the World Health Assembly (WHA) in May 1991. This goal was aimed at a reduction of leprosy-prevalence to less than 1 case per 10,000 population and was not aimed at reducing the incidence of leprosy (number of new cases). Thus, in this goal, the word "elimination" did not mean how ordinary people understand this term. Everyone involved in setting up the "elimination goal" knew that it was not possible to actually "eliminate" leprosy in the sense of "not having any new cases of the disease".

What was the rationale behind the decision of setting up this goal? The official reason was that if we could reduce the prevalence of leprosy in a population, the pool of infected persons would decrease and gradually the disease incidence will also decline. People and organisations working in leprosy control such as ILEP had opposed the "elimination goal" but were over-ruled (some of those discussions never really stopped and even today continue in some form on LML, 30 years after the decision of WHA).

Need for the Leprosy Elimination Goal

There was another reason, a more important one, for setting the Leprosy Elimination Goal. MDT, a new combination of drugs for treating leprosy was recommended by WHO Expert Committee in 1982. A review meeting organised by WHO on the progress in the implementation of MDT was held in Brazzaville (Congo) in 1990. It had shown that after 8 years of recommending and promoting MDT, globally less than 15% of the leprosy patients were being treated with it, while the remaining persons were still taking only Dapsone (in many endemic countries, the percentage was less than 5%).

I believe that this situation was linked to 2 other issues - (1) most of the leprosy programmes were being run by NGOs and missionaries, while the governments played little or no role in them; (2) the programme decisions were made by clinicians, who focused on individuals and not on the collectivity. Thus, while the WHO had been pushing for the adoption of MDT, doctors working in leprosy programmes felt that MDT administration needed their personal supervision and were hesitant to start it in rural areas where doctors were not available.

The "Elimination goal" was targeted at the governments, asking them to assume greater responsibility and, simplify and expand the use of MDT without requiring supervision of doctors and it achieved great success in reaching both these objectives - MDT coverage increased across the world and national governments took over the responsibilities for running their leprosy programmes from the NGOs and the missionaries.

International Pressure to Reach the Leprosy Elimination Goal

Fixing international targets and goals can motivate governments and people but it also has some side-effects. For example, for the leprosy elimination goal, once the  target was fixed, there was a lot of pressure on countries to reach the goal. If a country did not reach the goal then this meant that their programme was not good or their health staff were not working properly. On the other hand, there were insufficient discussions about the strategy itself, that reducing the numbers in high endemic areas within that period was not feasible because the other instruments to control leprosy (such as a simple serological test for diagnosis or a vaccine for its prevention) were missing.

When it became clear that many countries like India and Brazil would not reach the elimination goal by the year 2000, there were other effects. So, under the new WHO guidelines, treatment duration was reduced, active search for new cases was stopped and countries were encouraged to quickly integrate vertical leprosy programmes into their primary health care systems. All these measures helped in reducing the identification of new cases, the numbers decreased and India could reach the goal in 2005.

I remember the press-conference during WHA in Geneva in 2005, during which the announcement about "elimination of leprosy as a public health problem in India" was made as a triumph of the global health.

Impact of the Leprosy Elimination Goal

As explained above, the "elimination goal" was actually a "reducing the disease burden goal" and its objectives were to expand MDT and to improve government run leprosy control services. The elimination goal was successful in both these objectives. Expansion of MDT had a huge impact and millions of persons could be treated effectively and a large number of complications such as disabilities were prevented. Thanks to the goal and expansion of MDT, individuals affected with leprosy could be fully treated in 6-12 months and avoid most of the complications. Finally, for the health workers leprosy was like any other disease.

Once it achieved those results, ideally WHO should have clarified it and explained to the countries that we had not eliminated leprosy, we had only reduced the disease prevalence. However, that was not possible due to political reasons. Many persons involved with this issue in WHO had also started to believe that with reduction of disease burden, the disease transmission will be interrupted and the number of new cases will start deceasing, and were very optimistic. Unfortunately that did not happen and the fall in the number of new cases over the past 20 years has been much slower. The image below shows the participants in a WHO meeting in 2005 (Dr Lee, DG of WHO is in the centre, while I am the first on the left ) to talk about the leprosy elimination goal.

Reaching the "leprosy elimination goal" had consequences. Thus, in different countries across Asia, Africa and South America, reaching the goal led to many countries to scale-down their leprosy control programmes, even when they still had many new cases. Fortunately for countries like India, Indonesia and Brazil, their health professionals knew that leprosy was still a big issue and they could continue the leprosy programmes, but for many smaller countries, especially in Africa, achieving the elimination goal led to elimination of their leprosy programmes for many years.

This leads us to the question of the need for goal-setting and international pressure for reaching numerical targets. When your country is lagging behind in reaching an international target, what happens to its health workers? The answer is easy to guess - if they do not show the required impact on the disease condition in their work areas, they will be labelled as a bad workers and their programme will be called a badly-run programme, without looking at the real situation on the ground. So what are the options for them? In many leprosy programmes across the world, when their new cases did not decrease, many of them stopped registering new cases and therefore, manipulated their data.

For example, at the African Leprosy Congress held in Johannesburg in 2005, it had come out that Tanzania which had apparently reached the elimination goal in 2000, had actually manipulated its data for achieving the goal and the actual number of cases was still high. 

Unfortunately, the negative impact of the term "leprosy elimination" for this goal continues to create problems even today, because countries and health workers start beliving that do not have a significant leprosy problem.

For example, in 2016, I was involved in the evaluation of a leprosy programme in a couple of districts in central India. The evaluation showed that eleven years after reaching the WHO goal, district health officials were still confused about its meaning and many health workers complained that if they find "too many new cases" it created problems for them because the districts with higher number of new cases were seen as "bad districts".

Over the years, WHO keeps on finding new goals for the leprosy programme but the confusion created by "leprosy elimination programme" continues to exist and to create problems.

Let me now touch briefly on the "Impact of Health for All" goal of WHO. 

Failure of Alma Ata Declaration

Pai's list of failures of global health also includes the failure of the Alma Ata declaration and the goal of "Health for all by the year 2000". In his article, he had written that, "Failure to deliver on the Alma-Ata declaration: Despite the 1978 Alma Ata declaration on "Health For All by 2000", nearly half the world's population lacks access to essential health services."

Alma Ata declaration on the Primary Health Care in 1978 with its goal of "Health for All by the year 2000" was one of the biggest utopias which has motivated and mobilised the health activists all over the world for almost five decades. Even today, the echoes of that call continue to reverberate among us. I think that a summary judgement that the goal of Health for All was a failure, does not take into account the impact it had and continues to have even today, for example its influence on the discussions about the Universal Access to Health.

Fifteen years ago, I had some opportunities of talking about Alma Ata with Dr Halfdan Mahler, who was the director general of WHO during the Alma Ata conference and one of its main inspiring figures. Dr Mahler, originally from Denmark, had been working in the TB programme in India, before taking up the role with WHO (in the picture below, from left - Hani Sareg/Egypt, Armando/Brazil, I and Dr Mahler in Geneva during a World Health Assembly).

Some Achievements of Alma Ata Declaration

I think that Alma Ata declaration was an impossible dream but it was an important ideal at that time because it was so inspiring. I would not call it a failure, I think that it was and continues to be one of the most successful ideals of Global Health. It helped in achieving some important services - from my personal experience of working in international health programmes, three elements are mentioned below as an example:

(1) Alma Ata declaration and health for all was not a single goal. It had many elements in it, and many of them were implemented successfully. For example, the essential medicines and the programmes for fighting against different infectious diseases, both of which had a huge impact.

(2) For 30 years, I was involved in Community- based Rehabilitation (CBR) programmes (also known as Community-Based Inclusive Development or CBID) aimed at persons with disabilities in rural areas of lesser developed countries. The CBR approach was a part of the Alma Ata dream, which had developed independently because PHC approach was struggling for its own implementation. CBR also had a positive impact on thousands of lives of persons with disabilities and their families all over the world.

(3) Another related programme, which was inspired from Alma Ata and has been finally realised in the past couple of years is that of Priority Assistive Products list, which brings assistive technology to persons with disabilities and elderly persons.

I am sure that others can come up with many other examples of successful programmes which were inspired by the spirit of Alma Ata declaration. May be they were not fully achieved in 2000. Certainly, a large number of people still do not have access to essential health services, even in rich countries like USA. But a lot has been achieved since the Alma Ata declaration as shown by the evolution of global morbidity and mortality data across countries.

Impact of Other Factors

In terms of learnings from the Alma Ata declaration and the "Health for All by 2000" goal, for me a key take-away point is that health services and related goals can't be seen in isolation, they need to be looked at against the background of everything else happening in the world, including wars, famines and the role of international institutions.

I remember many discussions in People's Health Movement during which one reason had come up repeatedly for not having achieved a full primary health care (PHC) services approach across the countries - the decision by UNICEF to implement selected elements of child care because they felt that countries did not have sufficient resources for a full implementation of the PHC approach. Looking back, I don't think that UNICEF was to be blamed because in any case, the idea of providing free primary health care to everyone everywhere was an impossible dream in a world which was controlled by forces that did not see this as important or feasible.

During the debt crisis of the 1990s, the International Monetary Fund (IMF) and the World Bank, by promoting austerity policies, had hammered a big nail in the PHC's coffin. Since then, over the last 30 years, looking at health services purely in terms of numerical calculations of costs-benefits, cost-cutting and privatisation across countries, including those which had a good model of universal health care such as UK and Italy, has further taken us away from the Alma Ata trajectory.

A second Alma Ata conference was held in October 2018, which agained called for universal health coverage and sustainable development goals. However, I doubt that it is going to stimulate the dreams of activists around the world like the Alma Ata declaration had done in 1977. This may be also because today we live in a different world, a world of climate change, AI and internet, where new goals are set and forgotten all the time. The Millennium Goals have gone by, the Sustainable Development Goals are coming and setting international goals is a business strategy and not an exercise in idealism.

Conclusions

Pai's list of "global health failure" provoked me to write this post. As my explanations about leprosy and Alma Ata show, each of these points can be subjects of debates, and the answers may not always be negative. I think that similar provocative statements can be very useful to stimulate us to go deeper, study what had happened and reflect on the lessons we can learn from those expereinces.

A key point of Pai's article was that we don't learn from our failures. I am not sure if it is true. I think that the professionals involved in each of these "failures" must have debated and reflected on what happened and why for a long time, like we did about leprosy elimination. However, as time passes, all those discussions are forgotten and unless one takes the trouble of going back and reading through different point of views, the lessons learned can be easily lost.

(Note: an earlier version of this article was published in my blog in October 2021)

Liberal Dilemmas

I have always thought of myself as a liberal. However, increasingly I feel confused when I am faced with competing liberal values. Often, I am not sure, which values should be chosen and why. Most of the times, the more I try to read and understand about these issues, the more complex they seem to become. In the end, it leaves me frustrated because I can’t make any decision.

Even a decade ago, if somone had told me that I will be confused about my liberal values, I would not have believed it. It is not just me. Many others I know, face similar dilemmas, while some others, wh seem to have taken a positio, can't really explain their choices in a logical way.

So, lately I am not very sure, what kind of liberal I am or if I am really a liberal! One thing is sure, compared to some people’s certainties, I feel like a sand-castle whose walls fly off in all directions at the first sign of the wind.

Liberal Struggles in the Past

The identity struggles in the past were simpler. For example, fighting for the LGBT rights used to mean that countries and societies had to accept persons who identified themselves as LGBT, and that they were citizens like everyone else. Those struggles are still not over in many parts of the world. For example, in some countries, to be gay or lesbian or a transgender person can lead to blackmail, rape, prison, torture and even death. In addition to the specific anti-LGBT laws, in some countries, it is socially accepted that families and communities can force individuals into marriages, undergo conversion therapies, get raped or even be killed.

Countries which accept the individuals with different sexual orientations, might have other struggles. For example, their right to live with or to get married to the persons of their choice or to adopt children.

Often, most of our liberal struggles were framed in terms of limiting the role of religions and traditions in our lives. For example, when these impacted the lives of women and other marginalised groups such as "lower" castes in terms of where they could go, how they could dress or the professions they could choose.

New Directions of the Liberal Struggles

Over the past couple of decades, in the developed world those fights for the rights have branched out into new directions. Often, in these new fights, the rights of one group of persons start competing with another, and we have to decide which rights and whose rights are more important.

One big arena of fight is about the words we use to talk about things, especially in English. Thus, it is no longer about the intentions of the persons, or their histories of work in challenging the oppression and marginalisation of people – the moment they use some “undesirable” or "politically incorect" words and terms, they can be attacked, sometimes viciously, even to the point of destroying their reputations, jobs and lives. Every time this happens, it leaves me dismayed. People playing victims because their "dignity has been outraged" by the politically incorect terms are full of rightous anger and can be extremely unforgiving and vindicative. However, this article is not about the use of politically correct language.

Instead, in this post I want to share some of my doubts about some other liberal values - gender identities, religious/cultural identities, women’s rights and the rights of the persons with disabilities. Let me start with the dilemmas about gender identities in sport.

Identities and Sports

In the 2021 Olympics held in Tokyo, the New Zealand’s women’s weight-lifting team included Laurel Hubbard, who is now a transgender woman. 43 years old Laurel had transitioned to become a woman in 2013. In the past, she had participated in other Olympic games as a man. Many women weight-lifter teams from other countries protested against her inclusion since they felt that Hubbard will have unfair advantage. However, she failed to win any medal and in the end the polemics died down.

Lia Thomas, a transgender woman swimmer from Pennsylvania university has been in news in 2022, for her repeated wins in free-style swimming events. Thomas had previously competed in the men's team for three years before joining the women's team, the last time as a man was in 2019. Many persons had expressed anger at her success in the women's swimming events and called it as "unfair advantage". According to the local rules a trans woman must complete one year of the male-hormon suppression treatment before she can take part in women's events in Pennsylvania University.

Another story was that of Santhi Soundarajan, a middle-distance runner from Tamil Nadu in India, who had grown up as a female. In 2006, when she was 25 years old, her silver medal in the Asian Games was revoked because her DNA test had shown that instead of the “XX” chromosomes of women, she had “XXY” chromosomes. It didn't matter that Santhi had no idea about being genetically an intersexual person.

How do you feel about the stories of Laurel, Thomas and Santhi? Should they be allowed to take part in the women's events? In 2006, when I had read about Santhi, I had felt that the organisers had been cruel and unjust towards her. However, when I looked at the pictures of Hubbard and Thomas, I saw broad, tall and muscular bodies, and I could understand why the other women in the championship had felt that it was unfair. 

We have separate sports competitions for men and women, because men and women have different bones and muscles because of their hormones. Somewhat similar logic is used for the participation of persons with disabilities in sports – separate sport events are organised for them and they are asked to compete against other persons with disabilities, for example in Paralympics.

So, a person who has grown up with male hormones with a certain kind of bones, muscles and bodies, and who decides to transition to become a woman, should compete against other women or men? Women protesting against Laurel’s inclusion should be seen as persons’ fighting for women’s rights or as trans-phobic?

As a liberal, what should be my position on this? I have to confess that I am not so sure. For sports where body strength is not the most important variable, for example for playing tennis or badminton, I think that transwomen athletes won't have unfair advantage, but for something like the javelin throw, it can be an issue. While reading about Thomas's own behaviour at a swimming meet where she had won the title, I think that she herself is also conflicted about it. 

I have not seen similar discussions around trans-men's participation in sports and they seem to be accepted more easily, which is understandable because other men do not see them as "unfair advantage". For example, Moiser (Lake Zurich, USA) had taken part in the women's team of triathalon in 2009. A year later, he decided to transition to become a man and in 2016 became selected in the men's team.

Trans-men usually take the male hormone (testosterone) as part of their transitioning and on-going therapy while its use is prohibited among male athletes. So, I am not sure how does that work when they try to qualify for Olympics and Paralympics.

Defining the identity

There are many on-going debates around the issues of gender and sexual identities. For example, in some countries, transgender persons when they transition, can ask to be legally recognised as a man or as a woman.

In many countries, women transitioning to become a man must get operated to remove their uterus before they can be legally recognised as a man, while men transitioning to become a woman must get their testicles removed before they are legally recognised as a woman. This is done to avoid that a legally recognised man can become pregnant or a legally recognised woman can father a child.

However, many transgender persons feel that they have a right over their bodies and being transgender is more about how they feel in their hearts and not about compulsory removing of their body parts. Thus, there are trans-men who have their uterus and trans-women with functioning male genitals, and both these groups are fighting for the right to be legally recognised as men and women.

On the other hand, some other trans-men and women, who have been through surgical operations and have got legal recognition, feel that it is problematic if for being recognised as a trans person it is enough only to declare that you are one.

There are also debates about “real woman” versus “transgender woman”. Last year, in June 2020, a huge controversy had erupted about an essay written by the writer J. K. Rollings, who was called trans-phobic for differentiating between biological women and trans-women. Some weeks ago, Nigerian author Adichie Chimamanda has also been criticised for the same reason.

For not discriminating against the trans-women, some persons are advocating the use of more "inclusive" terminology, such as "chest-feeding" instead of "breast-feeding", and "birthing parent" instead of "mother". Many women have spoken out against these terminologies as they seem to negate women's rights and spaces.

 

I feel that these discussions about trans-women and biological women have implications for another liberal value – the respect for diversity. When we ask for trans-women to be seen as women, are we asking for negating the diversity of their experiences? The struggle for recognition of diversities has become very complex over the years. For example, many groups feel that the term “LGBT” is restrictive. Some ask that we should use the acronym LGBTQIA (Lesbian, Gay, Bisexual, Trans-sexual, Queer, Inter-sexual and Asexual), others prefer LGBTQ+. Some persons do not feel comfortable in any of these labels, they feel that they are somewhere in between. Some feel that their gender identity is fluid and can change, so occasionally they might fit one label, but not always.

Thus, on one hand we are advocating for increasing recognition of our diversities. On the other, we are asking of cancelling the diversities of terminologies between trans and cis women (many men and women do not like the term "cis"). As liberals, which value should be considered more important - equality or diversity? I am confused.

Religions, Traditions and Modernity

I grew up surrounded by discussions about patriarchy and women’s rights. In those discussions, the traditional Hindu wife, her face covered with her sari or a scarf, walking two steps behind her husband, was a symbol of women’s oppression under the guise of traditions. We agreed that women have a right to dress as they wish, choose the profession or work they like and marry the person they wish to. In those discussions, fights against the traditions were not seen as fights against the religions and in my mind, those discussions applied to all the religions. Thus, the fight for a common civil code, a uniform law that applies to all the persons of different religions in multi-religious societies, was seen as an important liberal value.

Over the past decade, suddenly such discussions have become more problematic. For example, the ban on wearing of full veil covering the face among Muslim women in some countries of Europe. The liberal position has sided mostly with the more orthodox groups by insisting that “Hijab and veils are cultural symbols and a free choice of Muslim women”. However, discussions with the cultural mediators working in the immigrant communities show that peer, family and community pressures and expectations play a large role in use of veils and hijabs, and sometimes, young girls face violence for rebelling against those pressures.

For example, Italy has a large Pakistani immigrant community. Last year, a young girl of Pakistani origin went missing while she was rebelling against family pressures. Police suspects that she was killed while the rest of the family went back to Pakistan. Debates among the Pakistani community on this theme underline the difficulties of talking about women's attempts to escape the social control on how they dress and the persons they wish to marry. Some girls insist that modest dressing including hijab is their free choice; others, usually men, at best talk of "not washing our dirty laundry in public because there is already so much discrimination against us" and at worst, threaten the few dissenting Pakistani women's voices about the perils of not obeying the "fundamental values of our religion/culture".

Sometimes, even in a European town you can find very young girls from Muslim background being covered from head to feet, while some see it as "sexualisation of young girls". The community spokespersons often talk of veils and hijabs as important for their faith. Recently in Afghanistan, the Taliban authorities have made maindatory the use of full veil by the women. So in such a situation, can hijab and veils be seen as "free choices"? Liberals refuse to talk about this because they see it as reinforcing the negative stereotypes about Muslims. 

Similar dilemmas face immigrants from Africa. Black persons in Europe are often stereotyped as drug peddlers and criminals. At the same time, many black women face domestic violence. Liberals often refuse to raise the issue of violence experienced by black women for not reinforcing negative stereotypes against the black communities.

Thus, how do we talk about the negative stereotyping faced by Muslims or blacks in Europe, without closing our eyes to the rise in conservative Muslim forces which increasingly force women and LGBT persons into silence or the black women victims of domestic violence? Is there a way to talk about one without negating the other? While talking about patriarchy is encouraged among Christians and Hindus, in relation to Muslim women it may be seen as Islamophobia.

The Right of Choice and the Right to Life

The women’s right of choice to say no to unwanted pregnancies and to have safe spaces for abortion was another of the progressive struggle with which I had grown up with. When I read about conservative groups, which oppose women’s right to have safe abortion, because their church says so or because Bible says so, I have no doubts about which side I am on – I support women’s right to make the choice.

However, over the past decade, increasingly there are groups of persons with disabilities, which fight is for the right of children with disabilities to be born and not be aborted. For example, one of the common reasons for abortion is when tests show that the child will be born with a disability such as Down’s Syndrome.

So, should we continue to support women’s right over their bodies and their wombs and only they can choose if they wish to go ahead with a pregnancy or should we be on the side of persons with disabilities asking for life for children with disabilities?

In the End

There are no easy or blanket answers to these dilemmas. At the same time, I feel that it is important that we continue to talk about them, without being trolled or called names by those who feel that they already have the answers.

Let me conclude with a couple of additional issues, which I believe are important liberal values – (1) not labelling people, and accepting nuances and complexities of peoples’ beliefs and affiliations; and (2) freedom of expression.

The moment we say something, there are people waiting to stick labels to our foreheads – right wing, left wing, fascist, communist, follower of this or that. I find this extremely tiring. I refuse to label people and I try to have a dialogue with everyone - when I find that I don’t like some of their positions or opinions, I can always ignore them. My motto is "the world is big and there is enough place here for people who don't think like me."

Finally, I believe in freedom of expression, even of people with whom I do not agree, as long as they are not actively inciting violence. I believe in people’s right to raise questions about every thing including religions, gods, and prophets. I do not agree with trolls and fundamentalists who want to cancel all the voices they don’t like.


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Notes

01: The images used in this post are from the Guwahati (Assam, India) LGBT Pride Parade in 2015.

02: An earlier version of this article was published in my blog in June 2021