Moral Determinants of Health? How is it Different from Social Determinants of Health?

There is a viewpoint in JAMA published under the title: "The Moral Determinants of Health" a couple of weeks ago.

I went through it and don't claim to understand it fully. But because there is a draft I'm working on about health as a fundamental human right, I think I understand what the author was meaning to say.

Social Determinants of Health (SDH) are things like gender, race, caste, occupation, etc which directly influence someone's health. According to WHO:

The social determinants of health (SDH) are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.

Where is the space for moral determinants when the definition of SDH includes a catch-all phrase "wider set of forces and systems shaping the conditions of daily life"?

I think the space is at a meta level.

Take race. Race, and racism are social determinants. But whether a society accepts racism and whether they want to change are moral determinants.

What is a society's moral stance towards the inequities within it? That is what moral determinants are.

For example, when it comes to COVID-19 and lockdown/quarantine, the social determinants are things like job security, government policy on lockdown, migrant status, etc. The moral determinant is the collective moral maturity to take into account such SDHs when doing things. Whether the government feels the need to consider daily wage workers when declaring lockdown. Whether people feel the need to pay their maids even when they can't come for work. Whether people consider it okay to isolate and discriminate against people infected with COVID. These are moral determinants.

That's why the author of the article mentions "right to health" multiple times. Right to health can be mistaken for a social determinant. It is a governance policy. A law. Something that can be included in the Constitution.

But no. Right to health is not really a social determinant. Having the right to health holds no meaning. Right to health is a moral determinant. It is only when people understand "right to health" through the moral compass within and appreciate the meaning of what it means when someone has a right to health, that right to health becomes meaningful. That is when people will become ready to make the sacrifices required to ensure health for all. Sacrifices like giving up the luxuries of capitalism, paying higher taxes, waiting for one's turn, and so on.

The reason why my post on health as a fundamental right is still pending is the same. I couldn't find a compelling reason to convey the moral argument behind right to health. It is dependent fully on whether people want to care for others or not. This is a fundamental moral argument. Should all people be equal? The proportion of people who justify inequalities in the society (either through economics, history, politics, or whatever) is the measure of how bad moral determinants of health are in that society.

Double Standards - Patanjali vs Glenmark; What is the Point of Ayurveda?

A couple of days back Glenmark made a press release about Favipiravir which made it sound like they have a "game-changer" and "magic bullet" (according to various media houses). This was based on little evidence about its benefit. There is virtually nothing in public domain that shows that Favipiravir is useful in COVID. CDSCO explicitly approved Glenmark to do this.

But today Patanjali is receiving flak and even has been officially asked by government not to advertise a drug they name "Coronil" which has very similar "research" to back it up. In fact, a quick look at the (?) methodology puts a placebo controlled trial by Patanjali at a better position to support the claim that their drug is useful.

Such double standards of Indian people and government.

Is this to do with Ayurveda?

We have no issue with Ayurveda. We have elected a government which set up a ministry for Ayurveda. In fact, this ministry was one of the first to come up with "prophylactic measures" for COVID drawing on Ayurvedic and Homeopathic medicine.

I personally believe Ayurveda is a science stuck in the ancient past. Thereby it is no longer science. But just because there are remedies mentioned in Ayurvedic textbooks, those do not become just Ayurvedic medicines. If those are tested with modern scientific methods, they are modern medicine too.

If not for research into Ayurvedic medicine that helps improve modern medical field, what is the point of running 250+ Ayurvedic medical colleges in India?

Is this to do with commercialization of Ayurveda?

Patanjali (and other companies) has been in the business of selling Ayurveda products commercially for so long. Surely, commercialization of Ayurveda isn't a crime.

Is this to do with private interests during a public health crisis?

Hasn't every damn thing we've been seeing in the past 6 months or so been about that? Can you name one thing which has been selflessly done for public health? If you named something, I bet it involves an individual or a group of individuals caring for the people right around them. I mean, if you see people suffering right in front of you but you are developing a solution for some others, tell me that there is no private interest in there.

Is this to do with scientific rigor?

Where was the question of scientific rigor in approving Favipiravir? Is any data available for that? Was evidence taken into consideration? Was it considered whether the people who generated the evidence were also the people who were going to market the drug? Has there been a peer reviewed publication?

What makes Coronil any different from Favipiravir? Is it that Patanjali's claim is 100% while Glenmark's is 88%? What if Patanjali claimed 99%? What is the right number for this game?

Is it that anything that has a name that sounds Greek and Latin is inherently good?

Like "hydroxycholoroquine", "azithromycin", "favipiravir". Is it the name?

Is it the fact that these drugs sound "modern"? What makes some chemicals modern and some chemicals ancient? Why can't all chemicals be just "chemicals"?

All these are rhetorical questions that lead us to the main part of this post.

What is the point of Ayurveda?

What are we doing with Ayurveda? What is the role of Ayurveda in today's world? Can we modernize Ayurveda taking the good parts and plugging out weaknesses?

Is there a way to re-imagine Ayurveda through modern scientific methods?

Can we apply the same standards when looking at evidence in both Ayurveda and modern medicine?

Have we extracted, examined, and integrated all the useful knowledge available in Ayurvedic textbooks into modern medical practice already? Is there perhaps a rudimentary theoretical framework in the way Ayurveda looks at wellness and illness? Can we build on that with the technological advancements that we now have to arrive at new theories on how to think about a human body?

I mean, is there a central theory in modern medicine? Except at the molecular level where there is DNA->RNA->Protein, what kind of dogmas do we have in modern medicine? Isn't there a need for such dogmas?

I'm not saying Ayurveda has a correct theoretical framework. In fact, if you go down the slippery slope, you might say that I will say that homeopathy also has the potential to provide a theoretical framework. I'm not saying that. From my limited understanding of homeopathy and dilutions, homeopathy seems to have nothing in it.

But Ayurveda is a different beast. Ayurveda was fairly useful during its time. It has sufficient nuance in its management algorithms to qualify for a thorough analysis. All I'm saying is, perhaps there is something to extract from it. And I'm saying this from my limited experience interacting with Ayurveda practitioners.

Nevertheless, why double standards?

Why do we trust "modern" medical "research" by default and distrust Ayurvedic "research" by default?

I mean, what does it tell you that a country which has no issue in pharmacies selling Ayurvedic medicine for every other condition says foul when an "innovation" is attempted for dealing with a pandemic that nobody has a clue how to handle?

When will we stop lying to ourselves?

Public Health Was Always Broken, You Are Just Noticing It Now

There is this nytimes article about how one pregnant lady who was also breathless couldn't find appropriate care despite going to multiple hospitals. I find it nothing surprising. Our country's public health system has never been able to provide appropriate care to people with medical emergencies (or for that matter, any health issue). Maybe now people are noticing because it comes on news.

There is a limit to how many emergencies can be handled at a time by a small medical team. Even in tertiary care government hospitals, this "team" is a very small one. It usually includes a couple of young doctors - either doing their internship or their residency. And a couple of nurses. And a couple of janitors. It is the same whether you are talking about the ICU or the emergency room of any department. There are no mechanisms for requesting extra hands when there is a spike in cases at any moment. Crises are handled by expediting care (many a times at the expense of quality and/or completeness).

Imagine this. You are attending to a very difficult accident victim with multiple dangerous bleeds and possible head injury and suspicious breathing. As you are assessing their breathing, another patient comes in with severe pain abdomen. The other doctor stops assisting you and goes to assess the patient with pain abdomen. And then comes in another patient who has a open fracture on both bones of one lower limb. Who on earth is going to take care of this new patient? Well, let's say the other doctor gives a pain killer to the patient with pain abdomen and let them settle down thus relieving themselves to attend to this new patient. At that moment comes in yet another patient with a head injury. What happens now?

It becomes worse in the ICU. You could be in the middle of a procedure and there could be a new patient coming in with lots of things to be taken care of. And another patient could crash as this is happening. There are so many things that can go wrong at the same time. But there aren't ever enough trained hands.

It is in such situations that doctors refuse to take patients. They know that they can't give justice to anyone if they take in more patients, especially critically ill. This is where "referral to higher center" happens. Anything can happen, actually - misdiagnosis, unnecessary investigations, miscommunication, death, so on.

What is the way out?

Of course, there are a lot of things that maybe potential solutions. But I do have one idea which seems sane.

Proper "professional" education in colleges

Nurses can perform any intervention done in an ICU if they are trained and empowered to do it.

Medical students should be made capable of handling cases on their own.

In an academic institution there is no dearth of learners. If learners are properly trained and given "professional" education, they can share a lot of workload. Similarly, our country needs to stop putting the doctor at the center of everything and start allowing other professionals like nurses to do more things.

Above all, there needs to be a culture of quality and improvement. This has to be built from within colleges. When such highly trained teams focused on quality come together, they can do debriefing, build protocols, and create Standard Operating Procedures for managing cases. They will figure out the weaknesses of the system and ask for infrastructure upgrade and many other things necessary to be done to improve the overall system.

Unfortunately, we are stuck in "long case, short case" mode in medical education. And this is not going to help the country.

Glenmark Lies About Favipiravir

I received from a friend a PDF which happened to be Glenmark's press release about Favipiravir. The release is full of claims that make it sound like Favipiravir is a wonder drug that is going to solve COVID problems. It becomes my responsibility to refute some of these claims, considering how majority media outlets are doing what they're best at - exaggerating an already exaggerated PR claim.

Firstly, we have to verify the claim whether India's drug controller did approve the drug. The way to do that is visit CDSCO's website and navigate to approvals -> new drugs. And as per that, "Favipiravir bulk and Favipiravir film coated tablet 200mg" did in fact receive approval on 19th of June for "the treatment of patients with mild to moderate Covid-19 disease" as the 18th entry.

I do not think CDSCO publishes details of the approval process, about what evidence they considered for approval, etc. Making these processes transparent would be useful for avoiding putting people in great danger.

The deceptions start from the title itself. "Glenmark becomes the first pharmaceutical company in India [..] blah blah blah [..] COVID" - what does it mean to say "first pharmaceutical company in India in this context? They just want it to sound like this is the first drug for COVID.

They then start with a bullet point about accelerated approval process which makes it sound like it was CDSCO who wanted the approval to be accelerated so that the "benefit" of Favipiravir can reach everyone. I doubt that's what really happened.

They then talk about "responsible medication use" and informed consent. The reality is that this informed consent is necessary because there is no way to know if Favipiravir is really useful in COVID. According to the Telegraph article, the approval was based on a trial on 150 patients. (The CDSCO website does list approval for a Favipiravir trial in May, although this was given to Cipla. Interestingly, the CDSCO website seems to be missing details of any approvals given in April (and Glenmark received approval in late April, as per them))

In that last pdf they do share the details of the clinical trial. They say they would enroll exactly 150 patients and give Favipiravir to half of them. 75 people!

Now, next in their bullet point they come up with the ridiculous and unsupported claim that Favipiravir shows clinical improvements of 88% and rapid reduction in viral load. In the text, they do add a citation which points to this PDF report of an observational study done in Japan. This was an observational study with no control arm or anything to compare with. The report itself states this:

  It  should  be  noted,  however,  that  this  study    only    captures    patients    who    received    favipiravir,  which  precludes  direct  comparison  of  the  clinical  course  with  those  who  did  not  receive  the   agent.   Given   that   over   80%   of   COVID-19 patients have mild disease which often improves by supportive   therapy6),   caution   is   required   in   interpreting  efficacy  of  favipiravir  based  on  the  data presented here

And this is what is cited to support the ridiculous claim in the PR.

I'm not going to go ahead and waste my time talking about each point made in the PDF.

But the fact is that saying Favipiravir is useful for treating COVID is as correct as this claim by Patanjali:

#WATCH We appointed a team of scientists after #COVID19 outbreak. Firstly, simulation was done&compounds were identified which can fight the virus. Then, we conducted clinical case study on many positive patients&we've got 100% favourable results: Acharya Balkrishna,CEO Patanjali pic.twitter.com/3kiZB6Nk2o

— ANI (@ANI) June 13, 2020

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Conflict of interest disclosure: I have 2 shares in Natco pharma worth about 1000 rupees the last time I checked.

What is a "Normal" Human?

Under the JK Rowling tweet about "erasing the concept of sex", I found an interesting article: You Can't Be a Feminist Without Acknowledging Biological Sex.

It brings up an interesting point:

The existence of people born with Syndactyly, for example, does not mean that humans don’t normally have 10 fingers and 10 toes.

I think this is at the heart of the debate. What is "normal" and what is not.

There is a wonderful TED talk by Aimee Mullins titled "The opportunity of adversity" (coincidentally, I had blogged about it 10 years and 2 days ago)

In it she brings a view of "disability" that should make anyone question the concept of normal.

Humans tend to call as "normal" what is "common". If 99% of people look and act in one way that is what most people call "normal". But "normal" has a connotation that is completely different from "common". The opposite of "normal" becomes "abnormal" - something to be corrected, something that shouldn't have been. And that's why the word "normal" creates all kinds of problems.

This has disastrous consequences. People with mental health issues are stigmatized against taking help because they get labelled "abnormal" by people who lack experience in understanding the spectrum of human existence. What is uncommon isn't abnormal. It is just uncommon.

Let's come back to the case of fingers. Do humans "normally" have 10 fingers or "commonly" have 10 fingers? What makes 10 fingers normal? Since we are using scientific terms like "syndactyly", let us also take a step back and look at the science of evolution. The way life evolves is through random genetic changes. All the diversity on earth (including human species) is the result of millions and billions of "mistakes" during cell division. Is there, then, anything abnormal about having a genetic makeup that causes a visible change in appearance from one's parents? Aren't there a lot of genetic differences between every individual on the planet (many of which perhaps don't cause visually apparent differences)? What is the rationale behind arbitrarily calling some set of human characters as "normal"? "Common", sure! But "normal"?

Let us take a human being born with 10 fingers. What if they lose a finger in an accident? Do they become abnormal? Sure they have lost a finger and probably a lot of functionality associated with that finger. You could call them "disabled". But watch the Aimee Mullins talk above again. Calling them "abnormal" creates unintended alienation. See how labeling people is a very hard thing?

That is the context in which saying biological sex can have only two normal values - "male" and "female" - creates problems.