Showing posts with label Social. Show all posts
Showing posts with label Social. Show all posts

Saturday, 11 February 2023

"Eliminating" Infections In India

In today's FirstPost, an online newspaper from India, there is a cover story on Neglected Tropical Diseases (NTDs) by Kalikesh Singh Deo, "a member of the Biju Janata Dal party. He is the Convenor of the National Coalition on Neglected Tropical Diseases and Malaria".

I have some concerns about the use of term "elimination" for reducing the number of certain diseases like Kala Azar and Lymphatic Filariasis, under the guidance of the World Health Organisation (WHO). I hope that bodies advising the Government of India would have discussions with stakeholders to ensure a reduction in the negative fall-out from the use of such terminology.

Let me explain why I think that using terms like "elimination" in such campaigns is a double-edged sword. (The image below presents some ASHA workers from Maharashtra, India - all public health programmes reach people through these front-line workers in India - without them no campaign or programme can work).

ASHA Workers, the courageous frontline health workers of India

WHO's Definitions

In 2016, WHO produced a document about the use of terms like "elimination". According to this document, the following terms have following meanings for the infectious diseases (page 3):

Control: Reducing the number of cases of a disease

Elimination: Reducing a disease to zero new cases (incidence) in a country or an area

Eradication: The causative organism has been eradicated from nature and laboratories so that it can not cause any new infection

In addition, there is a 4th definition, which is called "Elimination as a Public Health Problem" - this means reducing the numbers of cases of a disease so it is no longer a problem for the health services.

Advantages of Using terms like Elimination

In his article, K.S. Deo explains: "By December 2023, the Government of India plans to reduce kala-azar cases to less than one per 10,000 people at the block level and, by 2030, to eliminate haati pao as well."

Reading the strategy and such explanations, the readers feel that the problem is going to be solved. In this article, he does not use the term "elimination as a public health problem" because he understands that this won't make much sense to ordinary readers.

There are different advantages of using words like "elimination", including getting more resources from the Government and greater commitment from health services and health personnel.

There are real gains on the ground as well. For example, Deo writes: "10 February 2023, India will conduct Mass Drug Administration (MDA) rounds in Mission Mode in 10 affected states". This means that a large number of people will receive medicines to treat and to prevent new infections.

Disadvantages of Using Terms like Elimination

The first time the term "elimination as a public health problem" was used was in 1991, when WHO had launched its Leprosy Elimination Strategy (LES) - to reduce leprosy by the year 2000. At that time I was a member of the the medical commission of the International Leprosy Associations Federation (ILEP) and many of our members had concerns that people will not understand the term "elimination as a public health problem" and will think that the disease has been eliminated, they will believe that it no longer requires resources and services.

The LES had a huge impact in India. In most of north India very few public health services were reaching leprosy patients and most of them were being treated by older lesser-effective medicines. For example, due to LES, by 1998 even states like Bihar and UP managed to provide almost 100% coverage with newer and more effective anti-leprosy drugs to all those who needed them.

The problem came after India had reached the LES goal (in 2005). Many states reduced their support for leprosy services. It was not only decision-makers or general population who had thought that leprosy will be actually eliminated and there won't be any more new cases, even doctors and public health specialists believed it.

For example, 4 years ago, Dr Madhukar Pai, director of McGill International TB Centre and a well-known and influential public health specialist based in Canada, in his article "Failures of Public Health" wrote the following:

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

I can tell many anecdotes of people coming up to me with questions about why governments had declared "leprosy is eliminated" when they still had the disease. I have even seen a sociology thesis from a country in Africa, which had a theory about the LES declaration and a national conspiracy to marginalise the poor persons for the benefit of the rich.

Conclusions

I think that it will be good if Mr. K.S. Deo and his team will bring together different stakeholders, including representatives of leprosy-organisations to find ways which allow us to use the term "elimination" for the advantages it provides and at the same time, find alternate ways to mitigate the damage caused people's expectations that these diseases will disappear.

For example, it might be important to use some other word and not use the word "elimination" in the local language translations about the campaigns.

18 years after Eliminating Leprosy as a public health problem in India, it continues to be a public health problem and is a part of NTD strategy about which Deo has written. LES had an impact, the number of new cases of leprosy in India has been halved (partly this may be due to covid-related reduction in services, so that many new cases were not detected) but the disease is still there and it requires services. It is crucial to avoid mistakes of the past.

*****


Friday, 20 May 2022

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.

Alternative medicine treatment in Mongolia - Image by Sunil Deepak


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.

Dr Vijayan and Aurvedic treatment in India - Image by Sunil Deepak


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.

Alternative medicine treatment in India - Image by Sunil Deepak


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)

Wednesday, 18 May 2022

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.

A girl for a check-up for leprosy in a primary health care centre in India - Image by Sunil Deepak


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).

ASHA community workers showing materials used for leprosy diagnosis and awareness in the communities - Image by Sunil Deepak


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.

Participants in a WHO meeting on leprosy elimination in 2005


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.

Leprosy check-ups in PHC in India - Image by Sunil Deepak


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)

Friday, 13 May 2022

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.

LGBTQIA Pride Parade, Guwahati, India - Image by Sunil Deepak


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.

LGBTQIA Pride Parade, Guwahati, India - Image by Sunil Deepak


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.

LGBTQIA Pride Parade, Guwahati, India - Image by Sunil Deepak


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.


*****

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
 


Saturday, 2 April 2022

The Kashmir Story

Over the last couple of weeks, I have been reading about the film “The Kashmir Files”, its box-office success, its impact and the heated discussions it has generated. Perhaps, after a few weeks, it might become available on some streaming platform and then I will be able to watch it, though I am not sure that I will – from what I have read, it has some very graphic violence and I have no stomach for watching violence.

However, reading about “The Kashmir Files” has reminded me of another film about Kashmir and the Kashmiri Pandits – the film was “I Am” (2010), and it was directed by Onir. I think that it was a good film that merited greater attention. I had translated its subtitles into Italian, when it was shown at the River-to-River film festival in Florence.


The Kashmir Story in “I Am”

“I Am” was an anthology of four short films, loosely connected with each other. Among those four stories, the Kashmir short film was the second story of the film. It had beautiful performances by Juhi Chawla as Megha, a Kashmiri Pandit, and Manisha Koirala as Rubina, as her childhood Kashmiri Muslim friend.

This part of the film started with Megha’s journey to Srinagar to sell her house. Rubina comes to the airport to pick her up and is happy to see her old friend. Megha is by turns, angry and anguished, at the memories the return has brought back. She is unwilling to give in to romantic nostalgia about the city, and maintains some distance from her friend.

During the 24 hours of Megha’s stay in Srinagar, there are only a few scattered moments of nostalgia for her childhood home. A visit to the ruins of her uncle’s home who was killed by neighbours, brings back the memories of her terror of those days when they had abandoned their home and ran away to the refugee camp.

An encounter with a group of youth on the road, brings out that the story of the exodus of Kashmiri Pandits has been changed and retold by the locals. In this new retelling, they were the cowards and villains, who had run away from the valley.

At the same time, Megha’s dispersion of her father’s ashes in the river, brings out the attachment of older generations for Kashmir and their dreams about the day when they will return to their original homes.

Those 24 hours also show Rubina’s changed life in the Kashmir valley – she is lonely, living closed at home and is unmarried, while the guy she used to love has left India. Her brother, who had become a militant, has repented and come home, but is disabled and a shell of his former self. Police comes to their home frequently to check because they are a militant family. The city is divided by barbed wires and check-points, which gets deserted as the evening falls and people rush to their homes.

Megha’s righteous anger and resentment at the fate of Kashmiri Pandits, has one final moment of push back from Rubina. A brief exchange between the two friends, brings out the tragedy of changed lives of Kashmiri Muslims, especially those of the women and youth. The awareness that in the end there were no victors among the ordinary persons on the two sides plants a little seed of mutual understanding.
Impact of “I Am”

“I Am” was a film dealing with other difficult themes along with the Kashmir story. Perhaps that is why its Kashmiri section did not receive proper attention. It had a strong impact on me because in the process of doing its Italian subtitles, I had spent a lot of time with each of its scenes.

This part of the film gave precedence to the view-point a Kashmiri Pandit. It was shot in dark and drab colours. It showed a Srinagar of barbed wires, road-blocks and sad people, and not the romantic town of lake and gardens from 1980’s Bollywood.

The whole sequence of Megha visiting the ruins of her killed uncle’s house, had a very strong impact on me. Its background score was filled with the shouts of slogans by angry people asking all kaffirs to leave Kashmir or be killed. I could identify with her refusal of Rubina’s sympathy, when she responds, “Don’t worry, I am not going to cry”.

The film also shows the impact of the events on the other side, through Rubina’s family. They have also suffered and continue to suffer due to the militants on one hand and Indian army on the other. However, I felt that it was more difficult to empathise with them, because their pain was closely linked to issues related to militancy and its violence.

For example, there was a sequence when Megha is accompanied by Rubina’s mother to a neighbourhood shop for buying saffron. The elderly shop-owner remembers that he had accompanied Megha’s pregnant mother to the hospital when she was born. However, their discussion also brings out that it was that same person’s son who had killed Megha’s uncle and later, died as a militant. Megha comes back from the shop full of indignation – “You only had that shop to take me, whose son had killed my uncle?” she asks bitterly.

While I could see the dismay, regret and frustration on the faces of the local Kashmiris, I also had a feeling at the back of my mind that “it was their sons and families who did it”! I think that is the biggest difficulty when we look at victims of Islamic terror, that we are less willing to acknowledge the pain of its Muslim victims.

The Elephant in the Room

I remember talking to Onir in Florence about the Kashmir portion of the film, expressing my appreciation and saying that it was a great pity that this episode of our recent history had been allowed to be forgotten.

To write this post, I watched again the Kashmir portion of “I Am”. I think that there is an aspect of the Kashmir situation which had remained untouched in the film – the rise of more conservative Islam which was linked with militancy. Traditionally, the Kashmiri Islam has been moderate and open, and it had a history of a peaceful co-existence with Hinduism. Over the past couple of decades, the more conservative version of Islam has become more common, but its role and significance in the Kashmiri Pandits' exodus was never mentioned in the film.

Whose sufferings need acknowledgement?

As far as I understand about the events in Kashmir, the problems worsened with the Soviet invasion of Afghanistan at the end of 1979. To counter that the Americans started supplying money and arms to Mujahideen through Pakistan, which contributed to strengthening of the more conservative ideas of Islam in the region and reached Kashmir through Pakistani militants in the 1980s. Apart from the militants, it impacted different groups of persons, such as -Militants from Pakistan along with radicalised Kashmiri youth killed many Kashmiri Pandits and provoked their mass exodus in late 1980s and early 1990s.



Militants and hardliners from Pakistan along with their companions in Kashmir started killing moderate Kashmiri Muslims and those seen as sympathetic or collaborating with India, starting from early 1990s and continuing even now. Around 7000 Kashmiri “political opponents” have been killed, though some say that the Kashmiri victims have been many times more. They specifically target the intellectuals and they can abduct or rape their families.

Since the 1990s, Indian army has been fighting the Kashmiri separatists and militants and once again, a large number of victims have been reported, not only among the militants, but also among the civilians. The army rule has also affected general life.

Each of these groups have their own stories to share. I have read of Kashmiri Pandit families weeping at the shows of The Kashmir File - they are happy that finally their sufferings have been acknowledged through cinema. Onir’s film “I Am” did not show that violence directly, it focused on its aftermath.

I think that one of the good films about the impact of army in Kashmir was Shaurya (2008), which touched upon the human right abuses.

Stories about the situation in Kashmir involve different and complex issues. The views of the Islamic hardliners and militants may not be acceptable or understandable for most of us. However, I think that our cinema needs to explore these different areas and view-points so much more. For example, little is known about the violence against moderate Muslims in Kashmir and it would also benefit from a greater exploration in literature and cinema.

Friday, 25 March 2022

The Angry Indians

There are some persons on the Social Media, whom I call the "Angry Indians". They can be broadly divided into 2 main groups. One group is of persons who claim that they are trying to safeguard Indian culture and Hinduism. Often they have furious fights amongst themselves and some of them are full of hate. They often act in ways contrary to the beliefs they claim to defend.

The other group of that of persons who define themselves as progressives or liberals. They claim that they are trying to safeguard India's plurality and diversity. However, their main aim seems to be to counter BJP-Modi, and they are not really concerned about anything else. Like the first group, often they also act in ways contrary to the beliefs they claim to defend.

I call these 2 groups, the Hindu Cultural Warriors and the Progressive Cultural warriors. They are also co-dependent on each other, creating spaces for their fights and constantly, feeding-off each-other. Here are some recent examples of issues around which they fight.

India Versus South Asia

Recently the American vice-president Kamala Harris greeted the "South Asians" on the Holi festival and the Hindu Warriors erupted in protests. Don't you know that Holi is a festival only of Hindus of India, they asked. They don't like to be grouped together with India's neighbours, especially with Pakistan. On the other hand, Prograssive Warriors love using the term South Asia, I think mostly because Western progressives like it and even more, because they know that the other group hates it.

I need to confess that I am partial to Kamala Harris, since she has my mother's name, but my defense of the term "South Asian" has nothing to do with her name. I feel that the term "South Asian" acknowledges the common cultural identity of what was once known as Indian subcontinent. It is an identity which is shaped mostly by Indian culture, by its tradition of creating and accepting, even encouraging, blurred boundaries between the religions and its basic idea of "all the different paths lead to the same God".

All countries of South Asia have some Hindu, Sikh, Jain and Buddhists - in India and Nepal as majorities and in other countries as minorities. So wishing "Happy Holi" to all the people of these countries, did not seem like a bad thing to me and I can't understand why the Hindu Warriors don't like the term South Asians.

I can understand if conservative persons of other religions in "South Asia" resent Harris' greetings, because that is happening in some parts of the world. For example, there are many persons in Europe who get offended if you wish them for festivals which do not belong to their religions (for example, some Muslims get offended by the widespread Christian symbols in public spaces around Christmas and Easter times. So they are coming out with ideas like hiding Christmas trees in private spaces and saying "Season's greetings" instead of "Happy Christmas").

However, in India, festivals of all the religions are holidays for everyone and I have grown up in an environment where we wished everyone for all the festivals. For example, we always said "Happy Eid" or "Happy Gurupurab" and not "Happy Eid to Muslims" and "Happy Gurupurab for the Sikhs". So, if Harris is treating all South Asians as "people who celebrate Holi", why should the Hindu Warriors get offended? They should be jumping with joy!

Indian Festivals

Another issue which often leaves me confused is when Hindu Warriors get offended if someone dares to say anything about an Indian festival. I can understand the irritation about the extreme positions of some Progressives, who may be motivated by virtue-signalling - for example, their calls for "water saving" at Holi or for not making bonfires on Lohri and Holi. I can also understand the irritation because Progressives seem to focus only on Hindu festivals. However, I don't see the need to feel offended if someone says that Deewali can be hazardous for environmental pollution or the Durga and Ganesh statues pollute our rivers and lakes - I think that we need to look at these seriously and search for solutions.

Compared to other religions, Hinduism is not bound by any one book or any one tradition, so it is easier for us to question our old cultural practices and start new ones. For example, over past decade, I have seen different variations about the way we celebrate Rakhi, the festival in which sisters tie a rakhi on their brothers' wrists. Now, for promoting greater inclusion, some of our family celebrates it by sisters tying rakhis on the wrists of both, their brothers and their wives; and, at Karvachauth, both husbands and wives together keep fast. If we can change our rituals and practices according to the changing times, it is good for us as a community, and is certainly better than to remain with outdated practices and ideas.

Therefore, if the fire-crackers of Deewali cause horrendous increases in pollution and problems for people with breathing difficulties, especially in the big cities, and there are calls to limit their use, why should that be seen as an attack on Hinduism? IMO, it does not matter that traffic or industry or crop-burning are more polluting. On Deewali evenings, even 30-40 years ago, when traffic and other kinds of pollution were much less than today, the doctors' clinics used to be full of people with asthma attacks and breathing difficulties. I can vouch for it because I practiced medicine in Delhi in the 1980s and saw it every year. So why can't we use this opportunity to find alternative joyful and fun ways to celebrate Deewali? BTW, even Europe has campaigns around Christmas and New Year to limit the use of fire-crackers.

If chemical-based colours used in Holi can cause skin allergies or dermatitis, they also end up in our sewage waters and rivers. Our rivers and lakes are usually in terrible shape at festival-times. Use of chemical colours painted on the Durga and Ganesh statues, are bad for our environment in the same way. The answer for Hindu Warriors should not be to shout about these as "attacks on Hinduism" but to think of how to promote a wider use of plant-based natural colours. If we can promote our local artisans and organic colours' and dyes' industries by doing that, it will be even better. It can become an economic opportunity and also in line with our scriptures, which ask for the respect of nature.

BTW, the fun of Holi and the joy of covering people's faces and clothes with colours is increasingly finding emulators in Europe. Vicenza, the provincial town near which I live, has been organising "Holi celebrations" during summers, where it is an opportunity for people to drink, dance and play with colours.

Hinduism - Hinduttva

Many of the Hindu Warriors are promoting a version of Hinduttva which seems to be inspired by the ultra-conservatives of Christianity and Islam. Progressive Warriors are their partners in this, they also agree that Hinduttva means only that and nothing else. In fact for Progressives, the word Hinduttva belongs only to BJP, so they are fighting against it (they also think that the colour saffron belongs only to BJP and it should not be used).

I personally think that the word "Hinduttva" or the "essence of Hinduism" can not be reduced to only one meaning. Hinduism has developed along thousands of streams of ideas and practices across different parts of India, which have a lot in common and at the same time, an incredible amount of variations. Thus, if our ideas about Hinduism are infinite, the meanings of Hinduttva should also be infinite. So, why do we accept to let the idea of Hinduttva be hijacked by these 2 groups?

IMO, a wide public debate on the meaning of Hinduttva would be beneficial to India. It might help us to understand which cultural values are shared by the majority of Hindus and by majority of Indians. Though I don't think that we shall ever reach a consensus, this discussion would be useful. Probably, this commonly shared idea of Hinduttva would be closer to the results of the PEW survey in 2021 on the Religions of India. This survey report had shown that in spite of different religions, most Indians hold similar common beliefs. The "common shared cultural values of India" should be valued and safeguarded. Such an understanding of Hinduttva will be forged by the encounters of different religions of India and it will acknowledge the blurred boundaries between the religions, as one of its key characteristics.

The more conservatives among the Hindu Warriors do not accept anything except their ideas about traditions of Hinduism. At the same time, the ideas of blurred religious boundaries and common traditions shared across religious diversities are increasingly non-acceptable also to Progressives. They often talk about India's past and how it gave a home to persecuted minorities of the world, to cry about the lost Ganga-Jamuni tehzeeb and the lost traditions of accepting religious diversities in ancient India. However, for today's world they do not want to look at the norms and processes governing the acceptance of other religions in India's past. Instead, they would like to follow the ideas of secularism developed in the west, which are based on separation of religious identities. In India, the Progressive Warriors seem most concerned about how to safeguard the more conservative ideas of minority religions. I personally feel that the ideas of identity-politics developed in the west are problematic for a harmonious multi-cultural living in India because they destroy the blurred religious boundaries which has been a fundamental characteristics of Indian cultural world. For the same reason, Progressives defend maintaining separate specific laws for minority religions and fight the idea of common civil code.

Insulting Religions

Some of the Hindu Warriors are always looking for people insulting Hinduism, to fight with them. If you use a Sanskrit verse from a Veda in a rock-song or if you print the picture of a Hindu God on a bag or god-forbid, a pair of shoes or underwear, they are waiting to rise up and start a campaign to destroy you. The Progressive Warriors are willing to overlook all insults to Hinduism but are very careful in making sure that you do not insult the minority religions.

I think that the idea of "insulting God" is stupid because it does not fit in with the basic ideas of Hinduism, which include the belief that God is within each of us. "Aham Brahm asmi", "Aham Shivam asmi", "So Hum" - all mean "I am" or that "God is inside me". In Shrimad Bhagvad Geeta, Krishna shows his Virat Roopa to Arjuna to explain that he is there in every particle of this universe. These fundamental ideas should guide Hindus to the respect of nature and respect of every human being.

So, how can anyone justify killings in the name of Gods or religion if one believes in this teaching? If one believes that God is inside every being, how can anyone justify discrimination towards any person because of his caste or his religion? And, once you accept that God is there in every particle of the universe, how can anyone offend God?

Recently, I had read about people being killed in Punjab for "offending" the Sikh sacred book Guru Granth Sahib. I wondered if they had forgotten the story of Guru Nanak's travel to Mecca? The story says that some men complained that Guru Nanak was sleeping with his feet pointing towards Mecca and thus offending God. So, Guru Nanak told them, shift my feet towards another direction where there is no God. The story says that in which ever direction they shifted Guru Nanak's feet, Mecca appeared on that side. Therefore, the idea of Sikhs who get offended because someone disrespects their holy book and kill those persons, seems incomprehensible to me.

It is a pity that such messages of "offending God" are also spoken by people wearing saffron, who talk of beheadings and killings. Their saffron clothes should signify spirituality and learning. Yet, they can refuse the temple drinking water to a thirsty boy, because he belongs to another religion and say that they are defending Hinduism. How can they defend Hinduism if they do not believe in the ideas contained in the Veda and Upanishads?

IMO, Progressives have facilitated this rise in the Hindu chauvinism by closing their eyes to similar ideas and practices of conservatives of minority religions by suggesting that only the majority bigotry matters. Every time, there is violence or aggression involving persons of different religions, it seems that the Progressive speak out only if victims are from the minority religions.

In The End

The Hindu cultural warriors are convinced that if they don't save Hinduism then it is in great danger. The progressive cultural warriors believe that the problems lies only with the Hindu chauvinists and they are blameless. The thinking of both the groups is a problem.


Fortunately, in spite of everything, life goes on. I have great faith in common Indians, as shown by the findings of the PEW survey. I think that in spite of all the mutual hate expressed by the two groups, common Indians will find the right balance and a way to go forward.

Day before yesterday was 23rd March, the birthday of Doctor Saheb (Dr Ram Manohar Lohia), the iconic socialist leader, whose ideas had so much impact on me as a child. Today it is 25 March, the day on which papa had died 47 years ago at the age of 47. He was an associate of Doctor Saheb. If he was alive today, he would have been 94. Even after so many years, I miss him. I think that I would have loved to talk about the subject of this post to him and to Doctor Saheb - though I am not sure if they would have agreed with me!

Saturday, 2 January 2021

Religions For The 21st Century

Some weeks ago, I had a discussion with a friend about differences between Shamanism and Buddhism. I think that analysing religions to look for their differences is not such a useful approach in today's world. In the eastern traditions, usually the different religious philosophies are seen as different streams of the same river, and there is not a strong focus on analysing their differences. I think this way of looking at religions answers better the religious-spiritual needs of today.

A Buddhist lama in Mongolia - Image by Sunil Deepak


While humanity needs a spiritual dimension, the practical ways in which this need is expressed through religions depends upon the social, cultural, economic and technological context of the societies. Thus, it is inevitable that in the new millennium, along with our changing societies, our religions will also change.

This post is a speculation about what humanity needs from religions in the 21st century.

Religious Harmony

Like the different human species, the religious beliefs are also in continuous evolution. In the recent history, our different religions, especially the more orthodox religious ideas, have been one of the root causes of conflicts. In the medieval period, there were some attempts to come up with universal religions, which proposed unification of the different religious ideas. Baha'i religion in Persia and Deen-e-Ilahi by the Mughal king Akbar in India were examples of these unifying religions, but they had a limited impact because they were adopted by few persons, though Baha'i religion continues to thrive even today in a few countries.

Today, while we have some large radical and orthodox religious groups, many more persons identify themselves as "Atheists" or non-believers. A large number of persons, who formally belonged to a religion, define themselves as "spiritual and not religious". Many others, while belonging to one religious tradition, pick and adopt specific ideas of other religions.

A Jewish synagogue in Jerusalem - Image by Sunil Deepak


The pace of changes in the last one century and in the first decades of the present century, related to the technology and our understanding of the universe, has been unprecedented. When technology can give us the answers we need, we don't need to rely on the benevolence of Gods. So, some believe that in today's world we do not need any religions, because technology can provide all the answers. However, the mysteries of life, consciousness and death remain and every new child-birth and a death forces us to think about these mysteries, thus humanity's search for spirituality also persists.

St. Peter's cathedral in Rome, Italy - Image by Sunil Deepak


Science and Spirituality

I grew up in a family in India which was sceptical about our religion (Hinduism) and about the claims of different Gurus. Many persons in our extended family and among our friends share this view of Hinduism. However, I have met many persons who do not share this sceptical view of religion, they have no doubts about their faith. I recognise that faith does not need any scientific proof but personally for me, finding some kind of scientific rationale for the spirituality is important.

There are 2 kinds of technological developments, knowledge and understandings, which influence my spiritual beliefs:

(1) The first is our knowledge about the place of humanity in the Cosmos: We live on a tiny planet surrounded by billions of stars of our galaxy, and there are millions of other galaxies, each with billions of stars. The Cosmos is so big that even if we could travel at the speed of the light, hundreds of our life-times will not be enough to see even a tiny proportion of those worlds. This vastness of the universe is almost impossible to comprehend for me.

Even if among the billions of stars in each galaxy there can be only one planet which has life, there must be millions of planets with some life in the Cosmos. To believe that there is a human-like deity or an elderly father-like God looking after this unimaginably enormous universe made of trillions of stars and planets in millions of galaxies, who is observing each of us human beings living on our tiny planet and is keeping an account of the good or the bad things we do in our tiny lives, seems implausible to me. I can't imagine a God who has to look after millions of galaxies, worrying about things like if the people are going to the churches or mosques or temples to pray to him regularly or if women on earth are modest and covering their heads and bodies - these seem like ideas of men to control the others.

This understanding of the vastness of the universe leads me to believe that there is no personal God and instead the spirituality is something different. I think that prophets and all our ideas about the different Gods and Goddesses are metaphorical representations of the divine. Their stories and their teachings cannot be taken literally or in absolute terms, they need to be seen in their historical contexts, as answers to the human need for understanding the mysteries of birth, consciousness and death.

(2) The second development is our increasing understanding of the micro-cosmos through quantum physics: we still do not have a proper understanding of the quantum world which focuses on the laws governing the microscopic Cosmos hidden inside each particle of the universe. In that Cosmos also there are billions of sub-atomic particles circling other particles in an infinite number of galaxies of atoms and molecules. In this quantum world, the laws of the ordinary physics do not work, so that the sub-atomic particles can be at more than one place at the same time and the act of observation changes the nature of the observed sub-atomic particles.

To be honest, I don't understand most of it. At the same time, whatever I do understand, reminds of some of the concepts and discussions in the Hindu Upanishads about the nature of reality, probably because I am more familiar with those concepts and ideas. This world of quantum physics leads me to an understanding of God as the universal energy or a universal consciousness that underlies our atoms and molecules of all organic and inorganic worlds.

I like this idea of the divine as the universal energy with different levels of consciousness that moves the sub-atomic particles, atoms and molecules of billions of stars spread out over millions of galaxies. It unites all our universe and at the same time, leaves us free to use our intelligence to live our lives filled with a significance and meanings that we want to give to it. In this sense, I believe that God is the universal energy inside each of us and in everything surrounding us.

Religions for the 21st Century

In this world of increasing scientific understanding and technological progress, our religious beliefs face the challenges of reconciling science and technology with the ideas of spirituality. Different people deal with this challenge differently. While many individuals born in families with strong religious beliefs might share those beliefs, but many of those will question those beliefs as they grow up and as they find those beliefs limiting their life-choices. Many of us would form our own beliefs about the sacred.

The social media innovations allow us to find groups of people who share our niche beliefs and we can become part of their communities. Thus I think that the fragmentation of religious beliefs will increase exponentially over the next decades and the trend of picking and adopting aspects of different religions which resonate with us would become stronger with time.

AZ Al Khaldi Mosque, Gaza - Image by Sunil Deepak


This does not mean that persons believing in traditional religions are going to disappear. There is a subgroup of population, which finds a sense of security in specific and even rigid religious norms, and I don't think that subgroup is going to disappear anytime soon - probably with greater religious choices, these orthodox subgroups will also become stronger.

Among the leaders of traditional religions, those persons who can break-off from religious orthodoxy and can speak to the whole humanity, such as Pope Francis and Dalai Lama, will probably find even greater prominence in future.

The technical progress is increasing our sense of individual rights. Therefore, I think that the ideas of human rights are going to play an important role in our acceptance of religions in the 21st century. I think that issues such as equality of genders, rights of persons to choose their sexual orientations, the right to join or leave a religion, the right to live together with the person of our choice with or without marriage, the right to have a family of our choice and the right to die with dignity are all going to be basic starting points for the acceptance of religions of future.

Conclusions

These are my speculations about the future of religions in the world. I am sure that my views are influenced by my biases - those of growing up in a family sceptical about religions, those of being a part of a multi-religious family, those of reading Upanishads and those of my work-experience in the field of human rights.

Vivekanand Rock Temple, Kanyakumari, India - Image by Sunil Deepak


However, I am aware that history does not move in straight lines. It goes up and down, sometimes it takes two steps back before moving ahead. Looking at the conditions of specific religions might make us feel that instead of the changes I have speculated above, some religions are going in the inverse direction - towards rigidity, greater orthodoxy and a substantial denial of human rights. However, I believe that overall direction of history is different and sooner or later, all religions will join that direction, where the rights of individuals will be stronger than the rights of collective religious groups.

***

This Year's Popular Posts