Shrink's Views

ramblings of an unknown psychiatrist

Archive for the ‘economics’ Category

What is so posh about being unfashionable?

Posted by Dheeraj Kattula on January 12, 2011

Being fashionable is about being influenced by the current popular trend or style. On the converse being unfashionable is not being influenced by a trend. The most fashionable ones are the people who set that trend. Isn’t it? They had dared to be different from the existing scheme of things and charted the path of their liking. Look at the unfashionable person. The unfashionable person dares to be different by being stuck to what he likes. He might be frozen in fashion of a bygone era or he might be failed trendsetter whose style did not take off.

It is not considered cool to dare to be different as you like. It is considered cool to follow the trend-setters early on before your other friends. For if something becomes very common it is no more a fashion. One has to hurry to live in that fashionable period for the longest. If you join late, then it is already time for the next fashion.

What does the current new world with its emphasis on choice promise us? – Freedom to choose. Unfortunately with its tools of advertising we choose what they choose for us. They choose what is new. If I were to choose what I like I become unfashionable. I think it is cool to be unfashionable if you still think and choose for yourself.  Are you with the tide or do you dare to be yourself?

 

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Posted in bussiness, economics, social | Tagged: | 2 Comments »

The Dirty Job: a story

Posted by Dheeraj Kattula on August 27, 2010

My mother was admitted in the hospital. She had burnt herself. We went to see her every day. Our grand mother took us there. The doctors in the Government Hospital were not friendly. They would not let us stay in the burns ward for long. My mother suffered from burn injuries, which I still think were not very serious. I have seen many with worse burns make it to life. She died within a week of her admission. It was the doctors who killed her with their treatments.

Ramesh took Choti and left the village just after my mother’s admission into the hospital. Choti was born to my mother and Ramesh last year after they started living together. I think my mother knew she was going to die, even though she was conscious in the hospital. She wanted her family to take custody me and my other siblings Babloo and Moti. Her family is big. My grandma and her other children promised to take my brother. They did not want me or my sister. After all we were girls and they were afraid that we would grow up to be like our mother. I was seven years old and my sister Moti was four. An old lady in our village took sympathy on us and took us in. We addressed her respectfully as an aunt.

I missed my father and mother. My father was an alcoholic, but he loved us. He visited us every alternate day and gave us stuff to eat. My mother had wanted to keep him away from us. She used to shout at him, when she saw him meet us. I realize she too loved us. She was beautiful. We all look like our dad. Choti looked like our mom. I missed Choti too. My father never took another woman. He loved our family. A few months after mother’s death, I heard his body was found in a gutter in the neighbouring village.

This aunt who took us into her home was old. She found it difficult to control me. I was indeed naughty when I was small. I was always in the street playing with other girls. I did not help her as much as I troubled her. She put me into a hostel. I like school. I studied for five years.

In the summer holidays, I came back from hostel to be with my aunt. She was taking us to her native village. I refused. It was a dirty little village. We would have to share our room with two buffalos that they have. The smell was horrible. Instead of going I could stay alone in our village. She told her friend who lived few streets away to take care of me.

Her friend whom I called as Padma mausi took me to her house for a couple of days. She fed me well. I liked her. She took me to her aunt’s place which was few more streets away. The house had many young girls. They were all involved in dirty work. I knew that. My aunt too was involved in it, when she was young and able. There are no dirty little secrets in our village. Everything was open. Even primary school children knew what happened behind closed doors.

Our village had night school. It was where all children slept, when their mothers were busy with dirty work in the night. I knew it all, so I could tolerate it. I could accept the girls in the brothel. We played in the free time. I got good food there. It was better than what my aunt gave.

After a month, the care taker of the house called me into her room. A young man was there. She showed me to him and left the room. I was afraid. I screamed. He was strong. I could not fight. It was painful. I wept. He abused the care taker for giving him such a lousy girl like me. The care taker smiled and said, she is fresh to the trade. I was beaten that night for having shouted. Padma mausi never came again. Neither did my aunt. I was stuck there. I am now a 14 year old prostitute.

I could not leave the brothel. I was confined to the indoors. I had freedom inside. I could wear anything. I could eat as much as I pleased. I had the company of many girls, though many were older than me. Once you get used to everything you begin to enjoy what you once detested. I enjoyed the company of men. I liked the sensations of my body. When I lived in hostel, I liked Abdul. I dreamt of marrying him. His memories have got erased now. I lost the fear of men. I have seen them all. The rowdies who come and demand us for free, the police who are supposed to protect us, young men contemplating marriage, middle aged men who lost fancy for their wives and old men whose wives have died.

I was kept hidden for the fear of a police raid. I was moved from one brothel to another for protection. Indeed there was a raid and I was rescued. I was kept in a home run by the Government. Apparently my brother Babloo contacted a NGO and they had organized the rescue operation. I hate Babloo for having done this. I had adjusted to a new life. I was even enjoying it. I did not have to go to school. This rescue screwed my life up.

I was kept in this Government run home. I was not yet 18 years old, so I did not have right to be involved in this business. There were many girls like me in that home. Many of them were forced into it, just like me. They too began to enjoy their new life, just like me. They too were not getting any money, just like me. The men who came to us gave us money. We were to hand it over to the caretaker. She would give back a small amount to the older girls. The younger ones would only get food, clothing and accommodation.

After I joined the new home, they did some blood tests on us to check if I had contracted any disease namely HIV. I did not get it. The new home had a teacher who came to teach us some basic stuff. I was best in my class, as I had completed my primary school. Most other girls were dumb. I was getting irritated with their fixed schedule. I used to shout back to the teacher and the warden. They would beat me at times. They also taught us moral ways to live. I could see from the lives of our teacher and other staff that there are better ways to live.

I get confused at times about what is happening? The past and future flood me with irritation. I get tensed and do things that I later regret. I just cannot control it, when I get into that rage. Last year I broke the TV, Computer and telephone in a fit of rage. They thought I became mad.

They took me to a doctor. He admitted me in their hospital. He was a young man. He looked respectable. I saw him joking a lot with his friends in the hospital canteen, but he was serious with me. He looked straight into my eyes. He probably was mystified with my story. He had sessions with me regularly.  I avoided his eyes in the beginning. I became more comfortable with him and shared more freely. Of course I avoided many areas which were uncomfortable for me to discuss with. In fact I do not remember much of those either. He was interested in those things, as if they had a key to a treasure.

He asked me one afternoon, “You did not go to your aunt’s village because you would have been uncomfortable. Am I right?” I thought it was obvious. He then asked me, “If you had gone off to your aunt’s village, would you have gotten into this mess?” I was shocked. It is true; I would not have gotten into this puddle of shit if my aunt was around. She was old. She was in the dirty trade herself, but she was strong enough to protect us. He then said,” There are many things in life, which are uncomfortable. If we run away from them, then we would get into situations which are even more uncomfortable. Isn’t it?” I agreed.  He then added, “Can you see a difference between what feels good and what is good?” I did not understand that, but I nodded. He smiled and said “Good!”

He taught me how to relax my mind and how to ventilate my anger in acceptable ways. The day of my discharge grew nearer. He asked me of my dream. Of, what I wanted to be. I told him what I always desired, “A dancer, in the movies.” I could see his eyes sink. He was not happy. He tried to tell me that it felt good to be a dancer in the movies but it might not really be good. He said that the movie industry had risks for girls like me. He said it is likely that vulnerable people may get into wrong things.

I am sure I am not getting into bad things. I detest the dirty work myself. I would never do it to get a chance to be on silver screen. There is something called talent in this world and people would recognize and reward it. The doctor is educated. He can know what is in books. He cannot pick dancing talent. He has stereotypical beliefs on movie industry. Other girls in our hostel have danced on movie sets. They have told me that they did not have to do dirty work to get dancing chance. They told me the heroines do it not dancers.

When I got discharged, I could see that the doctor smiling. His smile was empty. It looked as if he knew something dangerous was lurking around. More knowledge spoils the mood for everyone.

Next year, they will release me from the home. I still am unable to love my brother Babloo, though he had done everything in my interest. It is probably because I fomented hatred over him just because he caused me the discomfort of moving me to the Government home from the brothel. I don’t care about Choti and Moti too. It has been many years, since I saw them. I have lost feelings for those whom I can call as a family. I can be a free bird with no restraints. I can chase my dreams. I can go to Mumbai and try my shot in movies.

Epilogue:

"The dirty job is always available."

After discharge from home she went to Mumbai to become a dancer. She fell in love with a light-boy. He left her after a year, leaving behind a two month old daughter in her hands. She was hungry and her baby had no milk to feed. She came to know why her mother sought Ramesh despite having a husband and three kids. The main roads are busy and side lanes are dark. The dirty job is always available.

PS: (added on September 25th, 2010) There is a sequel to this story ‘ Bollywood, Brothel and Being Born Again’.You can find it here.

Posted in behavioral therapy, bussiness, distress, economics, emotion, fiction, gender, indian society, personality, psychotherapy, social, stigma, women's issues | Tagged: , , , , , , , , , , , , , | 5 Comments »

“He will get bed sores and die in about three months. Take care of him. Feed him with what he likes.”: Medical Model VS Family Practice Model

Posted by Dheeraj Kattula on June 29, 2010

He was discussing about his experiences after he came down from the mountains. He was doctor doing medical work in the communities based in nearby hills. He was posted there by our hospital for a couple of months. Of the many things he told that day, I remember this story clearly.

He had seen a 74 year old man with a fracture in his femur in a hilly village. He asked me what he would have done. It was a simple answer for me. I said, “You would have told them to bring him down to the hospital. We could give some charity, even if they cannot pay fully. The bones can be fixed.” There were five competent orthopaedic surgeons in our hospital at that time. He smiled sarcastically. He wanted to make a point, but what he said shocked me.

He had said, “I told them, that he might not live very long. He cannot move here and there because of his broken hip. He will get bed sores and die in about three months. Take care of him. Feed him with what he likes. Let him enjoy the time he has.”

I was filled with malaise. What?!!! How can a doctor say this kind of stuff? I couldn’t control myself. I asked him, “Wasn’t it inhuman? Fractures are treatable. Isn’t it? Then why not offer it. How can we give a death sentence for a treatable condition?”

He laughed at me as if I was talking rubbish. I heard his argument keenly. Probably, it was to rubbish his argument to boost my egoistic ethical pride. He said, “Listen, this old man has a son who is the only bread winner. His daughter-in-law is a house wife. His grandson is now in standard 10. His grand-daughter is in standard 8. It costs about Rs 5000/- to bring him down from the hills in a vehicle. The cost of treatment in the hospital would at least be Rs 30,000/-. They do not have that much of money. If I do send them down, they will have to bring him back after a discussion with a orthopaedic surgeon. In the bargain they would have spent off large amount of money. Just in case they go ahead and treat him, they will have to sell off their house. If they sell it off, then they will have to live in the street.”

I was listening. He went on, “If they spend all that they have, the grandson may not pursue education beyond high school. The grand-daughter would have to discontinue school to add to family income. All this might add one or two more years to a 74 year old man. Is adding a couple of years to such a man worth losing the future of a whole generation?”

It was a tough call. I was a new graduate then. I was trained in the medical model. I was supposed to tell the best medical treatment available to the patients and let them decide what they wanted. I realized this model absolves me of any feeling of guilt. The truth is I do have in my mind what is better, but still I would have done what is ‘right’. My friend’s argument did not convince me.

After about 6 years of that incident I am wondering if that ‘right’ that I would have done is really right?  What would I do if I were in that old man’s position? I am absolutely sure I would rather wish a better future for my grandchild than live a few extra years. I have heard grandparents in India bless their grand children, “Let my years be added to you.” Of course that does not mean that one can assume this sentiment in every case?

The point is that my friend is a family physician. His expertise is not only in managing health problems at a primary level but also in understanding clinical problems and treatment options in the light of socio-economic conditions and the values of the family. His model makes people happier and fulfilled more than the medical model which has the appearance of being more scientific. May be it is time the specialists learn to use the broader model. This can be done when; in addition to eliciting clinical histories clinicians spend some more time with patients in understanding their and their family context and expectations.

PS: This event happened about 6 years ago. Today, thanks to Chief Minister’s insurance scheme and 108 ambulance services, patients like the one described can get free treatment in our hospital.

Posted in challenge, children, Diagnosis, distress, economics, education, ethics, indian society, medicine, philosophy, social | Tagged: , , , , , , , , | 3 Comments »

Whistle blowers- Beware: a story with notes

Posted by Dheeraj Kattula on June 25, 2010

Have you heard of the term ‘whistle blower’? I would save you the trouble of clicking an external link to understand this term by sharing what the Wikipedia says as on 24th of June 2010. A whistleblower is a person who raises a concern about wrongdoing occurring in an organization or body of people. Usually this person would be from that same organization. The revealed misconduct may be classified in many ways; for example, a violation of a law, rule, regulation and/or a direct threat to public interest, such as fraud, health/safety violations, and corruption. Whistleblowers may make their allegations internally (for example, to other people within the accused organization) or externally (to regulators, law enforcement agencies, to the media or to groups concerned with the issues).

The organization that I work with abides by the laws of the land, rules and regulations formed by itself, health and safety norms and works in public interest. It is very open to listen and is keen on being a ‘learning organization’. It only requires some time and energy to walk to a senior and put forth your views. The ideas will be taken note of and discussed. One need not fear any reprisal.

Unfortunately many organizations are not like that. You can read this story from Riverbank Laundry Inc. It is a modified version of a story I heard as a child. It does have lessons to be learnt in the context of working in organizations and on being a whistle blower.

Dhobanna was CEO of Riverback Laundry Inc.  Riverbank Laundry was a one man organization which had a human assistant and two animal assistants. He worked on banks of a river. His  two animal assistants were- Kuki, a dog and Gardhab, a donkey. He washed clothes in the river and let them dry in the sands of river bank. Kuki would keep a watch on those clothes as they dried. In the evening Dhobanna would pack all the clothes and load them on Gardhab. Gardhab would carry all the clothes back to Dhobanna’s house a mile away. His wife would Iron those clothes and then Gardhab had to carry these to the homes of the clients. On the way back, Dhobanna would have a ride on Gradhab.

The business situation in the region was like this. Many had entered the laundry market. There were no entry barriers. It required no major capital investment. All that one required was a clientele. Usually people managed it from the street of their residence. Dhobanna’s Riverbank laundry was an old player. It existed in that town for at least 5 generations. Dhobanna cut his costs and kept the price low to retain his market share. He continued to grow despite the competition. In the bargain Kuki and Gradhab were losing on their daily nutrition and they had to work more to cope with his market.

Kuki started resisting passively. He would intentionally look away if a thief was eying some clothes to steal in the hot afternoons in the river bank. He wanted his master to get insulted by his clients for losing their stuff. Dhobanna’s growth attracted attention of local thieves. One night they broke into his house. Kuki and Gradhab were tired after a day’s work, but they were still awake.

Kuki looked away. Gradhab told Kuki, “ Bark, Kuki…Bark. Wake up our master. There are thieves in our home”. Kuki replied, “Gardhab, I am tired of Dhobanna. Fellow is starving us and squeezing us at the same time. Let them loot him of the booty he made from our toil. I want to see him cry tomorrow morning. If you want to so loyal, go ahead and bray.”

Gardhab brayed hard. He wanted to wake up his master. Dhobanna had had a tiring day. He woke up. He was furious at his donkey for waking him. He grabbed a stick and rushed to the back yard. He started beating Gradhab, incessantly. Gardhab brayed more trying to get his attention to the problem. The more he brayed, the harder Gardhab got hit. Gardhab stopped after he could not bray more. Dhobanna went back to his bed.

Kuki slept silently in a corner. Next day Dhobanna found his house cleaned up. All things worthy of mention were gone! He cried out loud. He went to the back yard. He found Gardhab lying on his side. He went close. Gardhab’s eyes were open wide and blood which had oozed from his nose and ears had dried. Gardhab was not breathing. He was long gone. His master had beaten his loyal servant to death. Kuki was watching all this at a distance. He lost his friend. His master lost his everything. Even if Kuki were to be thrown out, he could always make a living outside.

Reflection:

Was security on Gardhab’s job description?

No.

Was he not recruited for logistics?

Yes.

Did Kuki do the right thing?

Passive resistance is found in organizations, but it is picked and addressed.

Did Gardhab do the right thing?

We all feel he did the right thing, because we see the bigger picture that he saw. He worked in the interest of the company. He went beyond the text of his job description. He was not a right fit into the job. He was too good for that job. His boss did not understand his integrity or his competence. In working for a wrong boss and wrong company Gardhab paid with his life.

Should we blow whistle in our organizations?

Yes, if it is going to be taken seriously. No, if it makes no difference and especially if we might attract reprisal. If the issue is crucial and goes against the personal values a person stands for, then it may be better to leave the job. It is not our business to change a company’s values to our personal values however good they might be.

Posted in economics, management | Tagged: , , , , | 2 Comments »

Family’s (poor)BCG analysis of children : Sons as ‘Stars’ and Daughters as ‘Dogs’

Posted by Dheeraj Kattula on May 11, 2009

let them shine

A few weeks ago I skimmed through a book* on Strategic Management. I came across ‘Boston Consulting Group (BCG)’s portfolio analysis. It is based on product life cycle theory that can be used to determine what priorities should be given in the product portfolio of a business unit. It feels uncomfortable comparing a family to a business unit, but interestingly the word ‘economics’ is derived from ancient Greek and means laws of management of a ‘household’. So, there should not be a problem with studying unwritten ‘business’ laws in a family. What has that got to do with sons and daughters? Let us see…

A family decides how much resource is to be allocated to each child based on certain values and this affects the future trajectory of each child. My previous post was on society’s obsession with having sons. In this post, my point is that ‘maleomania’ might also not be useful.

Let us study a modified version of BCG’s portfolio analysis. The two dimensions in which children (products) are to be rated are Growth Potential and Domestic Productivity. My intuition is many young boys fit in the ‘problem children’ category as they do not contribute much in the house-hold chores and are perceived to have a high growth potential. Young girls on the other hand help their mothers in their domestic work. There is indifference to her growth potential. So most likely an average girl falls into the ‘cows’ category.

Domestic Productivity

Growth Potential

high

low

high

Star

Problem Child

low

Cow

Dog

How do managers deal with ‘problem children’? They increase investment in product development or encourage retrenchment into speciality niches. If son is not studying well in studies, what do parents do? Send him for tuitions, coaching classes, cricket coaching (at least he can use sports quota), personality development workshops etc. If he is absolutely not fitting in, parents would plan sending him to some uncle’s place to learn business!

Daughters on the other hand are like BCG’s ‘cows’ which keep producing/ serving the family without much scope for growth. In the adult years, when the focus is on the son’s produce/ service (economic/social), the daughter’s share (domestic) looks small and she is perceived to be a ‘dog’. If the family accepts her well it is the case of a ‘faithful dog’ if not it is sadly that of a ‘mangy’ dog! The manager’s solution for mangy dogs is disposal, in this case in form of marriage!

The model is supposed to work for the benefit of the family economy, though I have seen it failing. I have been observing the problems faced by old people. There was an old lady, who was admitted in our Hospital with acute watery diarrhoea. She needed intravenous fluids for some time. She has five grown up sons. None of her sons was willing to be her caregiver. A salaried son of hers arranged a caretaker of another patient to also look after his mother!!!What is the use of having five useless sons?

What is the least expectation from children? Reasonably, that they take care of parents in their old age. What is the guarantee that a son would surely take care of parents in their old age? One can only hope that the proverbial budape ki lathi does not give a stick to the old parents. In the yester years, when society was agrarian, it was expected that eldest of the sons would take care of the parents.

Changing demographics shifted the responsibility to one of the sons who ‘could’ take care of them. This shift was pragmatic and not driven by social norms. So, even if a family abandons their old, there are no issues raised by others. In the modern era, when people have fewer sons, the probability that all sons would fail them is more than if they had more. I am not presenting a case against family planning. I want to argue that sons need not be stars working in interest of their family. They could become druggies, they could elope, they could be ‘hen-pecked’, or they could just abandon their parents.

The society always had capable girls, who provided in the domestic front and if need be in the community too. Please read this post for such a story. Given an opportunity, girls can achieve all that boys can. The society is changing. Women are entering workforce. Roles in a marriage are changing. Women too earn for the family and men help in domestic chores. In such context, I am sure responsible girls would provide for their aged parents. The BCG analysis forgot that with time, management itself would change! If the family considered a daughter as a star and had invested in her growth there are possibilities that the daughter proved herself worthy, even more than what could be imagined.

Intuitively, it is expected that sons move from ‘problem child’ status to ‘star’ status and daughter’s descend from ‘cow’ status to ‘dog’ status. In real life despite odds against them many daughters shine like stars and in spite of receiving all inputs few sons go to dogs.

Is it worth killing an unborn girl child (a potential star) for having a son (a potential dog, God forbid)? …………………………………………………………………………………………………………………………………………………………………..

*Ginter PM, Swayne LE, Duncan WJ. Strategic Management of Health Care Organizations. 4th edition (2005). Blackwell Publishing

Posted in bussiness, challenge, economics, gender, indian society, management, social | 7 Comments »

Psychiatry and Principles of Economics

Posted by Dheeraj Kattula on May 4, 2009

In his book ‘Principles of Economics’  N. Gregory Mankiw highlights 10 essential economic principles. I had a few random thoughts on how these relate to psychiatry. Consider the fact that psychiatry deals with psychiatrists, patients, pharmaceutical companies and other allied health workers.principles-of-economics2

The 10 principles are

1. People Face Trade-offs.

2. The Cost of Something is What You Give Up to Get It.

3. Rational People Think at the Margin.

4. People Respond to Incentives.

5. Trade Can Make Everyone Better Off.

6. Markets Are Usually a Good Way to Organize Economic Activity.

7. Governments Can Sometimes Improve Market Outcomes.

8. A Country’s Standard of Living Depends on Its Ability to Produce Goods and Services.

9. Prices Rise When the Government Prints Too Much Money.

10. Society Faces a Short-Run Trade-off Between Inflation and Unemployment.

Let us consider these in detail with reference to psychiatry.

Most people do not have means to get what they want. But within the constraints of resources available, all people face trade-offs (scarcity). They have to decide what to give up for getting what they want(opportunity cost). Rationality helps them consider the marginal cost and marginal benefit before making a decision (marginal utility).

Technically, marginal benefits and costs are calculations made at the margin – with the aid of calculus. True, all of us have some sort of calculations. But, how far they correspond to the marginal concepts is still an open question in Economics. Recently, with advances in neuroeconomics, behavioural economics and game theory, such notion of rationality is being increasingly contested.

Since, Mankiw’s book adheres to the undergraduates, contradictions and controversies within the discipline of Economics are overlooked so as to provide a rosy picture of the discipline. Mental illness affects the way a person can make decisions. In psychopathological terms it is called ‘loss of judgement’, which can affect a person’s interaction with ‘psychiatry-market’ and also affect the person as an agent in the economy. For this, one does not require marginal benefit and costs analysis.

For example a schizophrenia patient may not want to come to mental health facility saying that doctors are poisoning him, a manic patient may spend thousands of rupees in a buying spree, an OCD patient may regularly buy large amounts of washing powder etc. What is the rationality of getting a heroin shot by sharing a needle, when one considers the risk of getting HIV, the risk of being caught by the police for drug related crime? Just A HIGH ? Are not the marginal costs ignored and marginal benefits considered badly necessary by a junkie?

Though, economists have termed these junkies as being irrational, it is possible to counter-argue that the process and way of calculating the marginal cost and benefit is different for the junkie. Different variants of rationality has been put forth in the literature – bounded rationality, unifying models, rule based behaviour, reciprocity, etc.

People respond to incentives though we are not certain how the incentives and behavior are connected. Their behaviour changes when costs or benefits change. When marketers use psychology in economics to tempt people to buy things they may not need, psychiatrists use economics in psychiatry to motivate patients to do what is needed!

A strategy used to treat negative symptoms in schizophrenic patients is called ‘token economy’. In child psychiatry incentives are used in treating behavioural problems.  All therapy is, to an extent altering the values placed by clients on different choices to promote a desired behavior.

Trade can make everyone better off (benefits of free trade). This includes patients, their relatives, health-care personnel, pharmaceuticals etc. People do not go to mental health services as they go to a theater. They have no choice not to go/trade if they understand their need. We have seen earlier that psychopathology can affect them from trading despite their need.

The asymmetry of information gives the doctors a lot of power on the economics of psychiatry. They are the ones who prescribe medicines. No one can question their decisions as they are board certified. Are they so sophisticated that they do not respond to incentives of pharmaceutical companies to push their drugs? Are their decisions based purely on clinical dimension? In the transactions there are not many risks on for the psychiatrists in the trade, except the case of a legal suit against them. On the other hand the patients have all the suffering- disease, drug costs and drug side effects. With escalating costs patients could be worse off!

It is traditionally believed that markets are a good way of organizing economic activity (laissez faire). It is assumed that households and firms that interact in market economies act as if they are guided by an “invisible hand” that leads the market to allocate resources efficiently. Consider the map of psychiatric services. They are always concentrated around urban areas. Supply usually goes to where there is demand with a greater paying capacity and not where there is ‘need’. Markets ought not to determine the activity in health-care.

When a market fails to allocate resources efficiently, the government can change the outcome through public policy (help for market failure). The government has to intervene and have its own services or has to finance people’s cost of care to some extent in needy areas. It should also give incentives to set up services in areas of need.

I do not find it easy to conceptualize the interaction between macroeconomics and psychiatry. I still attempt to do so.

Standard of living of people depends on the amount of goods and services they provide. As productivity grows, so does the average income. Though it is true that a service would earn more, when they produce larger service per unit time, in the case of psychiatric care, cutting down time or increasing work per staff would harm the very nature of care. Mass production of psychiatric service is not possible. So how would standard of living of those involved in supply improve, remains an economic problem. From the patient perspective, psychiatric services are good. They encourage occupational rehabilitation both for economic and therapeutic reasons. So psychiatry improves standard of living and quality of life of patients.

The value of the money falls, when a government prints large quantities of money (quantitative theory of money). As a result, prices increase, requiring more of the same money to buy goods and services. This makes care inaccessible for the mentally ill, who might not be in a very good earning state due to the disease itself.

The case where the Government printing a lot of money helps the patients and providers is when the Government does demand side financing for psychiatric services or provides subsidies. Few economists argue that the causal link between money supply and prices is debatable. Especially in today’s globalized world, an increase in money supply by printing money cannot/need not lead to an increase in prices.

Society faces short run trade-offs between unemployment and inflation (Philips curve) . This relationship is believed to be true by one section of economists belonging to the Neo-classical camp. It is not and should not be considered to be a universally valid proposition. In neo-classical understanding reducing inflation could cause a temporary rise in unemployment. This trade-off may be crucial for understanding the short-run effects of changes in taxes, government spending and monetary policy.

Prevalence of mental illness is not big enough to pull the rest of the economy in any direction. Inflationary effects on drug prices and service prices would have a negative impact on the ill and providers. Remember that inflation is a stress and can lead to ‘breakdown’ in people who are predisposed to it. One could argue the need to work can be a motivating factor for a mentally ill person in the light of rising prices. But consider the fact that motivation itself could be affected in mentally illness. For a patient inflation does not get him employed more than mental illness helps him get unemployed!

You can clarify issues posting your comments.

Reference

1.http://www.slembeck.ch/principles.html

Posted in economics, psychiatry | Leave a Comment »

“I will pay in full for I promised to sell my land”

Posted by Dheeraj Kattula on April 29, 2009

He was sick from Makara Sankranthi season. He muttered to himself and beat his wife black and blue. He shouted obscenites and village people avoided him. He was suspicious of people harming him, so he kept aloof. He suspected hisown  father to have a realtion with his wife. That was the reason that he was so irritated with his father and aggressive over his wife.

His beliefs overwhelmed him and he wanted to die. His father brought him one evening and he had to be given chemical restraints (pychiatric medicines in form of injections )before he could be admited. Injections are not painless. His backside was aching continuously after he recieved few shots. He understood that the hospital staffs are supportive. They give injections but also him give ice packs and comforting words. He started taking oral medicines.

He responded within a week. His hallucinations came down and his delusions were loosing their grip on him. He beacme very loving towards his wife and father too. He wanted to live, have children, educate them and do well. Nearly two weeks from admission, it was time to get discharged. His father wanted to pay ‘full’. We offer people to pay prospectively too. A poor family becomes much poorer following a hospital admission. When we asked again he said he now had cash, so it was no problem. I asked him, how he got that cash. I could then smell the handia, the local rice beer from his breath. He said he promised off to sell 6 ghunt land for Rs 6000/- . This was to pay a bill of Rs 1800/- !!! When we did not mind it being paid in installments without interest !!! One could suspect the balance amount would run down his throat within a couple of weeks as alcohol. I told him to cancel off the deal and pay whatever he could from his own reserved. He had about Rs 1000/-. Rest was to be paid over 8 months as Rs 100/- per month.

What is the possibility that this family with a schizophrenia patient would default? Minute. The whole purpose of admission was to remit the symptoms AND educate the family on drug compliance issues. Basically driving home the fact that He will do well as long as he takes medicines. Can’t you see how medicines have helped within the last few days? If he stops medicines, he will be back to the way he was. At that time these medicines may not work. We will have to then go for costlier medicines.If you want to stop medicines for financial resons and you do it, you would end up spending more!’

There is less chance for a patient to leave psychiatric services here and go anywhere else as the over all costs are cheaper and quality of services provided are better. Quality measured in the ‘time spent with patient’ and ‘time spent with family’.So there is less chance of losing to the competition.

Occupational rehabilitation is encouraged so patient becomes economically productive in ways such that in the long run cost of treatment is seen as an investment in generating income to the family.

I hope to see this patient back after 20 days from now. I do not want to see him as a psychotic in patient again i.e. I wish treat him in the OP for rest of his life. I know I can only wish…

Posted in challenge, distress, drug therapy, economics, schizophrenia | Leave a Comment »

Bayes’ theorem and charity

Posted by Dheeraj Kattula on April 27, 2009

Lionel Robbins defined economics as “the science which studies human behaviour as a relationship between ends and scarce means which have alternative uses.” When working is resource poor a setting economizing becomes all the more important. A hospital, which wants to serve the poor keeps its general prices low lest the poor never come. Despite this patients would require a dicount in form of ‘charity’. How is it that a hospital can try its best to see that they give charity to the poor and only the poor? 

What are the combinations possible? In the descending order of preference for probability of such a combination happening is:-

1. patient poor ( Po )-recieves charity( C )

2. patient not poor( N Po )- recieves no charity (N C )

3. patient not poor- recieves charity

4. patient poor-recieves no charity

Practically it is very difficult to know for sure economic status of a patient. Poor tribals come to hospital in their best dress even when very sick. I have seen the rich go to labour rooms in stinking clothes as they know they would discard that apparel after the delivery!

We know if charity is given or not. Is it possible to use Bayes theorem by looking at conditional probability of the given combinations and apply it to formulate direction of the services?

Bayes’ theorem can be expressed as :

simple

 

 

Which can be expanded as :

longer1

 

 

Each term in Bayes’ theorem has a conventional name:

  • P(A) is the prior probability or marginal probability of A. It is “prior” in the sense that it does not take into account any information about B.
  • P(A|B) is the conditional probability of A, given B. It is also called the posterior probability because it is derived from or depends upon the specified value of B.
  • P(B|A) is the conditional probability of B given A.
  • P(B) is the prior or marginal probability of B, and acts as a normalizing constant.
  • The denominator is Probability of occuring without considering occurance of A. There for it takes conditional probability of B when A occurs and also when non-A occurs.

Intuitively, Bayes’ theorem in this form describes the way in which one’s beliefs about observing ‘A’ are updated by having observed ‘B’.

Let us consider person has received charity. What is the probability that he was poor?

probability of person being poor given that he has recieved charity P ( Po/C )

According to Bayes theorem:-

P (Po/ C) =                        P ( C / Po ) . P ( Po )

                         ———————————————————-

                               P ( C / Po ) . P ( Po ) + P ( C / N Po ). P ( N Po )

We know that P (C/Po) cannot be known. If it was then we would not look at this equation at all as P (C/Po) is our main interest. Then P ( Po/C ) would be high when

1. P ( Po ) is high

2. P ( N Po) is small.

That is if one wants to give charity to poor only, he should start a independent entity where only poor come. Then he can give charity with greater confidence! He can have another set up for the non poor where there would not be any charity. Horizontally well integrated organizations can effectively run such systems if they have such a vision.

Ops! In a single set up, there needs to be optimization of some sort. My plan is to think on this and post it in future.

 References

1.http://en.wikipedia.org/wiki/Economics

2.http://en.wikipedia.org/wiki/Bayes_theorem 

Posted in bussiness, economics, mathematics | Leave a Comment »

lesser the better

Posted by Dheeraj Kattula on April 26, 2009

She was 26 years old. A mother of a three year old child. She was well dressed and well kempt. An old patient of ours brought her to our OPD ( out patient department ) for vague somatic complaints that she had been having for the past 2 years. She was not keen expressing her problems as well. I usually enquire regarding stressors even in a general OPD. To me young hesitant woman ususally means- domestic problems with husband or mother-in-law.

She lived in a nuclear family and her husband was very loving. As I probed into her more deeply, I realized that the patient was quite severly depressed and was also having suicidal ideation. I encouraged her attender to admit as soon as possible indicating high suicidal risk. She wanted to come the next day. A hospital admission is not that simple.

Patient’s families have to hand over their cows and hens to others to care for. They should arrange for someone to take care of their feilds. They also need to arrange for cash. Most payments are out of pocket in rural India. They need time to go and bring utensils, rice, dal and oil to cook nearby. Most importantly they should arrange for someone to stay as an attender.

She came the very next day for admission with her husband. I could see her in detail. She revealed that she had been hearing voices that others could not for the past two and a half years. She had also been suspecting few relatives of doing witchcraft against her. She was barely able to do her household work. She was managing well, due to her extremely suportive husband. Clearly her diagnosis was Paranoid Schizophrenia- continuous course.

I started her on antipsychotic Risperidone 2 mg. In the evening hours I spent time with her husband regarding her illness, its nature, course, treatment strategies, prognosis and outcomes. The voices in her ears came down within 3 days. I had planned to go up on the dose to 4 mg before discharge. I decided against it. Many a time we go up on the dose rapidly expecting results quickly. Thoogh many patients might respond at lower doses.

She bacame aware of her problem as an illness. She feels there is no reason to die if her voices go away. She has hope that treatment is helping her. Why go up on the dose? The patient is not going to run away anywhere. If she does not respond with 2 mg over 2 weeks then I would go up.

By increasing her dose to 4 mg would I not double her treatment cost? It she develops extra pyramidal side effects (tightness and rigidity), she would require medicines to control that. This would triple her cost. By being conservative in a relatively safe situation benefits are fewer medications, better compliance, lesser cost, lesser side effects and probably better effectiveness.

Posted in drug therapy, economics, schizophrenia, suicide | 1 Comment »

value, price and ethics

Posted by Dheeraj Kattula on April 26, 2009

A patient called us ‘dacoits’, a well meaning staff informed me. It is unthinkable for a team like ours, who chose to work for the poor to be perceived as a dacoits. That too by a patient! 

Why did that happen? The patient was ‘educated’ in the sense that he looked at maximum retail price (MRP) of drugs that we had issued and drug charges billed to him. There was a small discrepancy, which to him looked like daylight dacoity.

We buy drugs from good generic manufacturers like CMSI, LOCOST etc.We incur much higher costs of ordering, transport and stocking these generic medicines than brand ones. The brand suppliers call up to take orders, pay for the transport and at times give discounts also.

The generic ones do not offer these, so our costs are higher and margins lower. The MRP on their labels is less than break-even price for us. So I charge little higher than MRP. I believe it is right to do so. Even if I was a consumer I would have preferred this to buying branded medicines in pharmacies outside.

Why do we continue to use generics despite certain logistic difficulties?Let me illustrate with two drugs commonly used by psychiatrists.

 price-tableIt is far cheaper for the consumer to use generics. It is loss making for the hospitals, considering their other costs. So I use generic medicines for patients sake. When one sees the difference between the hospital’s price of generic medicine, which exceeds its MRP, one might conclude robbery in broad daylight. Asymmetry of information would never let him know that for few medicines, he has paid just about 5% of the market price!

One of my own staffs questioned me if charging more than MRP to cover costs is ethical! I think it is, if I want to deliver value to maximum number of patients by reducing their overall health-care expenditure. Look at the other option of stocking brand drugs, we will have profits but would alienate many poor due to high costs.

I can choose to do what looks good to others and what is easier for me. But then, I might end up harming many more people (especially the poor) than the few (in general middle class and the rich), who get dissatisfied with this way of charging. What do you think?

Posted in economics, ethics | 2 Comments »