A great discussion on the history of India’s tech.

On February 27, the Bangalore International Centre and Carnegie India hosted a panel discussion around Midnight Machines, the new book by Arun Mohan Sukumar that traces the interplay of technology and politics in independent India (read The Wire Science‘s review here). The panelists were Arun (my friend and former colleague at The Hindu), space entrepreneur Susmita Mohanty, Rajya Sabha MP Rajeev Gowda, historian of science Jahnavi Phalkey, and Anu Singh of Carnegie India.

The whole discussion was about 90 minutes long, and picked up steam after the first 15 minutes or so. If you’re at all interested in the history of science and technology in India, I recommend you watch the whole thing on YouTube. If not, I’d like to draw your attention to two a few interesting (to me) passages of discussion and which I’ve also transcribed below. The parts where Arun and Phalkey directly debated each other, Arun emerged with only minor bruises, which I shouldn’t have to tell you is a considerable feat and may not have been the case in a full-on, two-person debate!

Jahnavi Phalkey, 32:00 – The political ambition of a state is now technological ambition. That’s why the technological story of the latter half of the 20th century is a political one, and is therefore also political in India. The other aspect of this is centralisation. While we in India have argued that the Indian state centralised research funding through the CSIR, DAE, the space programme, etc. with all money going into a few facilities, look at Europe. The European answer was CERN, with countries coming together to build facilities. Apart from the UN, there was no economy then that could conduct scientific research at the scale the tone for which was set during the Second World War.

Therefore, the centralisation solution adopted (also) in India was no different from what was happening globally. So what was happening in India was not anomalous. It’s a part of the larger story. To add a footnote to the Nehru story: Nehru spoke science, he said “scientific temper”, but look at the institutions he established: the IITs (when it was 60 years before India setup the IISERs) and the CSIR (he didn’t go for the Max Planck Institutes model, the Kaiser Wilhelm Institutes model or the Harnack principle but focused on industrial research); the IISc came 50 years before independence. So the accusation that Nehru spoke science, did science but didn’t do technology is not held out.

[At one point, Arun also talks about how India needed a Nehru to navigate the Non-Aligned Movement to still secure favours form different governments without upsetting the precarious balance of powers (so to speak) to help set up some of India’s preeminent IITs. I skimmed through the video twice but couldn’t find the exact timestamp.]

Arun Mohan Sukumar, 43:50 – A CSIR scientist said the failure of the solar cooker project basically ensured that all the scientists [who worked on it] retreated into the comfort of their labs and put them off “applied science”.

Here’s a project commenced almost immediately after independence meant to create technology by Indians for Indians, and after it failed for various reasons, the political spotlight that had been put on the project was counterproductive. Nehru himself investing this kind of capital exposed him and the scientific establishment to criticism that they were perhaps not used to. These were venerated men in their respective fields and they were perhaps unused to being accountable in this visceral way. India offered a prototype of the solar cooker to Egypt and, I believe, Rhodesia or South Africa, and the joke goes that the order was never repeated. D.D. Kosambi says in an opinion piece at the time that the only person who made any profit out of the solar cooker affair is the contractor who sold it for scraps.

This is the kind of criticism confronted by the scientific establishment and it is a consequence of politics. I agree with Prof Phalkey when she says it was a consequence of the political establishment not insulating the scientific establishment from the sort of criticism which may or may not informed but you know how the press is. That led to a gradual breaking of ranks between the CSIR and the political vision for India where you’d have these mass technologies that [Phalkey] mentioned, and you can see the best evidence for that is Nehru’s pursuit of massive industrialisation in the second Five Year Plan, from 1956 to 1961.

This isn’t to say that Nehru was surrounded by advisers who all believed in the same thing; there was of course [P.C.] Mahalanobis who believed in a more aggressive form of industrialisation. But at various points of time one constituency was trumping another, within even the establishment. But it needs to be said that the PM was not in favour of introducing tractors in agriculture… Again, this is all criticism with the wisdom of hindsight.

Jahnavi Phalkey, 53:16 – In the 1970s, look at the number of democratic regimes that fell due to hot wars fought during the Cold War in the rest of the world. You’ll start to see why the need for control was felt.

Arun Mohan Sukumar [following after Rajeev Gowda’s comments], 55:05 – Another dimension is the presence of universities in the US, which incubated the military-industrial complex. Harvard and MIT in Boston and Stanford in the Silicon Valley were the nuclei for research. In India, some of these are truly unfortunate circumstances that the government has no control over. When the first batch of graduates passed out of IIT Kanpur in 1965, Lyndon B. Johnson passed the Immigration and Naturalisation Act giving Indians, and people of other nationalities, an automatic path to citizenship. So the best minds of our country were prompted by the fact that there aren’t enough jobs or enough well-paying jobs in India [to enter] a feeder line created between India and the US, from which it is very difficult to come back. Those circumstances too must be acknowledged.

Susmita Mohanty, 56:20 – Even brain drain is hugely exaggerated. I’ve lived in four different countries. The talent pool we have in India today is as big or bigger. There are people leaving the country but not everyone is the best coder in town.

Arun Mohan Sukumar, 57:24 – The appropriate technology movement that started in the late 1960s and early 1970s was this philosophy that grew out of Western Europe and the US which called for lesser consumption of natural resources and labour-intensive jobs with a view to conserving resources for the planet, a lot of which was precipitated by a report called ‘Limits to Growth’, which essentially predicted this catastrophe that would befall humanity by 2000.

And then economist [E.F.] Schumacher writes this book called ‘Small is Beautiful’ [in 1973] and creates a revolution incidentally not just in advanced societies but also in developing countries, where leaders like Indira Gandhi coopted the movement to say to the people that you should consume less, conserve your natural resources and deploy labour-intensive technologies that will essentially be beneficial to you and your way of life. Seminar after seminar was organised by top institutes of the time to talk about how you can create fuel out of biogas, how you can mechanise bullock carts – technologies that are not scalable but nevertheless are quick-fixes, and this is where ‘jugaad’ has its historical origin: in the valorisation of frugal innovation.

[Phalkey shakes her head in disagreement.]

This would’ve been acceptable had it not been for the fact that investments in the space and nuclear programmes continued unabated. … So on the one hand the state was promoting big science and it wasn’t as if they had an ideological or political compulsion against Big Machine and big technologies. There was just factors such as financial considerations and the government’s own inability to develop technology at home which, I argue, led Indira Gandhi to co-opt the appropriate technology movement. … In India, perhaps it’s harsh to say that we moved backwards, but the objective was not to redefine technology but to shun it altogether. [Phalkey is quite in disagreement at this point.] That unfortunately is I feel a byproduct of the legacy of the 1970s.

Jahnavi Phalkey, 1:01:14 – I have to disagree because there’s been only one science plan in the country in its history, and that was done in the 1970s under Mrs Gandhi’s regime. Eighteen-hundred people from user ministries, the Planning Commission, scientific institutions and industry sat together over 18-24 months and came up with a comprehensive plan as to how to take research happening in the institutions and in the CSIR through Planning Commission allocation of money to the user ministries. We haven’t seen anything on this scale before or since.

Problem was as soon as Mrs Gandhi implemented the plan, she also implemented the Emergency. When the Emergency was pulled back, the Morarji Desai regime decided that India did not need [the science plan]. So the argument you’re making [addressing Arun] of scaling back on technology or technology as a solution to the social, political and other problems that India had was more due to the Janata regime and not Mrs Gandhi’s. One needs to make this small distinction because this was simply not true at the time.

Arun Mohan Sukumar, 1:06:09 – What was remarkable to me while writing this book was this factoid that comes from this book on the history of computing in India by C.R. Subramanian: he says the import of computers to India tripled during the years of the Emergency. For my life, I can’t imagine why! But it goes to show that despite the anti-automation protests of the 1970s and 1970s, and remember that 1978 is the year when IBM quit India for whatever reasons, there was beginning to be this gradual embrace of technology and which really takes off from the 1980s. And from the moment of liberalisation in 1991, it’s a different story altogether.

Some of these legacies continue to haunt us, whether it is popular protests against nuclear plants, which really came of age in the 1960s and 1970s, not just in India but also in other parts of the world. Some of that really bore on India as well, and I believe continued into the debate on genetically modified crops. If you ask a person who really has a strong opinion on these subjects, I wonder whether he or she would have a clear idea of what the technology is. But they evoke such strong views, and perhaps some of it is due to the constant politicisation of the virtues and vices of the technology.

Arun Mohan Sukumar, 1:09:04 – One of the reasons why the Indian opposition to the Human Genome Project was so pronounced in the early 1990s, when the hand of invitation was extended to the Indian government, was because the Vaccine Action programme signed by Rajiv Gandhi and Ronald Reagan just a few years ago ran into a great deal of controversy within and without government; defence ministry officials said here is an effort to take DNA materials from Indians to be turned against India as an agent of biological warfare, and all sorts of rubbish.

[How history repeats itself!]

Adding to this, some private institutes in the US were involved in smuggling anti-rabies vaccines into developing countries. All of this spooked the scientific establishment and which, the book argues, led to us staying away from the Human Genome Project.

… And we missed the bus. Today we say we are able to map the genome of some man from Jharkhand at a fraction of the cost – it is at a fraction of the cost because most of the work has already been done. There is some historical legacy there that unfortunately continues to haunt us.

[Susmita Mohanty mentions ISRO’s famous reluctance to share information about components of its civilian space programme.]

Jahnavi Phalkey, 1:12:26 – There’s also a little bit of politics to it. The information that NASA and ESA share is backed by a very, very, very strong politics of sharing. What can and cannot be shared are clearly divided.

Jahnavi Phalkey, 1:13:57 – If you begin with Robert Clive, we have a history of about 300 years of building suspicion. And to dismantle that kind of suspicion is going to take lots of work. I’m not saying to not have participated in the Human Genome Project but that it’s not a good thing to share or that we embark on certain projects. I think we might be erring on the side of caution.

Arun Mohan Sukumar, 1:17:58 – There are different kinds of technocracies, and the three people surveyed in the book [who represented those kinds] are M. Visvesvaraya, Vikram Sarabhai and Nandan Nilekani. They forged three different organisational structures within government (of course Visvesvaraya did so before independence), and they had different views of technology. I wouldn’t say there were all political animals but they certainly had a good appreciation of politics which was crucial to their success.

For example, Visvesvaraya was a very astute navigator of colonial-era politics but then resigned as the diwan of Mysore over what he perceived as anti-Brahmin protests in the Madras presidency and the threat of that spilling over into Mysore. Finally, after independence, his views were totally marginalised by the establishment of the time.

Sarabhai was in currency throughout but also in many respects was able to tell the leadership what it wanted to hear and at the same time insulate his own team from politics to the extent that ISRO today has a separate recruitment process. Some degree of autonomy was built-in.

Nilekani’s work on Aadhaar goes the exact opposite way: he is very clear that he does not want scientists or technologists running the programme beyond the infancy… He was very sure at the beginning that an IAS officer should be running UIDAI. We can debate the merits of the decision but the fact is, in his view and the view of the team, the technocracy could only survive if it was built from within government. Whereas when Sarabhai died, Satish Dhawan was brought from Caltech to run ISRO. It was very clear for the folks behind Aadhaar that that model would not have survived.

fin.

Featured image: The panelists (L-R): Arun Mohan Sukumar, Susmita Mohanty, Rajeev Gowda, Jahnavi Phalkey and Anu Singh.

Three overlooked reasons why India’s healthcare indicators remain abysmal

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January 2, 2015

The Bharatiya Janata Party-led Central government announced in July that it would roll out a National Health Assurance Mission, whose aim would be to provide some free medical services to reduce “out of pocket spending on healthcare by the common man”.

It is thought that the NHAM could be active as early as this month, and could cost $26 billion, according to a senior health official. This is a noble gesture: according to a report on healthcare costs in the BRICS countries (Brazil, Russia, India, China and South Africa), out-of-pocket expenditure pushed as many as 60 million Indians below the poverty line in 2010.

Going by a Planning Commission report accessed in May, India spends only 1.04% of its GDP on publicly-funded health, while its total health expenditure (public and private) was 4% in 2010-2014. The same report aspired to increase public health spending to 3% of GDP by 2020 and to 4% by 2025. A lot has changed since then, especially when the Narendra Modi government cut down the health spending by $900 million for 2014-2015 citing lack of funds.

Nonetheless, the reason India’s healthcare indicators remain abysmal is not just a question of money (after all, ours is one of the fastest growing economies). The problem is a persistent rash of doublespeak that denies the people a coherent healthcare system. While successive governments have committed to various goals, no government programme has yet focused on the three most important problems facing India’s health at once: a mismanaged regulatory climate, corruption, and the caste system.

1. Contradictory regulations

The problems with regulation are illustrated by India’s medical tourism industry, which according to government sources will be worth Rs 9,500 crore in 2015, and as much as Rs 54,000 crore in 2020. Almost 75% of the medical imaging equipment (worth Rs 18,000 crore in 2011) that services this industry is imported and the value of imports themselves grew at a compounded rate of 16% in 2010-2014.

There is an import duty on fully-finished devices to the tune of 10%, whose cost is transferred to consumers. It gets better here: if device components are imported individually and then assembled in India, there is an additional excise duty and VAT, increasing the device cost. This tax suppresses domestic manufacturing of diagnostic equipment and the import-intensive economy it fosters continues to inflate healthcare costs in a country where only 30% of healthcare is publicly funded.

It has also led to a chicken-and-egg squabble between medical advocacy groups in the country. For example, ahead of the presentation of the Union Budget in 2010, the Department of Pharmaceuticals sought a cut in the customs duty to facilitate imports, while the Association of Indian Medical Devices Industry sought a hike to promote domestic innovation.

The report that claimed out-of-pocket expenses had pushed 60 million people below the poverty line also found that urban centres were the primary users of sophisticated medical equipment even as the per capita expenditure on medical technology in the country was a frugal $2 to $2.5.

2. Corruption and Inefficiency

A part of the problem is corruption and inefficiency. There is no national body to oversee the procurement and provision of generic medicine, which currently originates from local manufacturers known to operate their plants in unsanitary conditions. On April 7, the day Sun Pharma announced that it would fully acquire Ranbaxy Labs, Wockhardt publicly acknowledged that its plant in Aurangabad had been found to contain urine and mould in the vicinity of testing samples during an inspection by the US Food and Drug Administration.

All three companies now are disallowed from exporting certain drugs to the US and Europe. The reason they are allowed to release their drugs in the domestic market is because there is a demand for generic drugs and because there are about 1,500 health inspectors for more than 10,000 factories in the country, resulting in one in every 22 locally-produced samples being of substandard quality. In Tamil Nadu alone, 4,000 health inspector positions remained vacant in 2012.

Moreover, public healthcare professionals are not up to the mark. As the recent Chhattisgarh sterilisation camp tragedy illustrated, medical camps are often understaffed by ill-equipped doctors and technicians. One surgeon at the Chhattisgarh camp reportedly performed 83 tubectomies in six hours. In Odisha, cycle pumps were used to dilate the cervices of some women in a sterilisation camp.

Data from the Ministry for Health and Family Welfare shows that, since 2008, 700 people have died after going through government-sponsored sterilisation programmes.

3. Caste system

What exacerbates all these issues is the social setting their providers and users are situated in, and the caste system in that setting. On November 20, Arundhati Roy gave a lecture at the University College London, titled “The half-life of caste: The ill-health of a nation”. She started by saying, “We are still a society where a public health worker will refuse to touch children who are ill because they are untouchable. There are doctors who refuse to do a post-mortem because it’s polluting to touch” a dead body.

She argued in the lecture that the notions of purity and pollution that casteism enshrines, whose persistence M K Gandhi secured by institutionalising them during the freedom struggle, often deter good health practices, especially among poor women and children and those belonging to the lower castes. As the chart below shows, India’s infant and maternal mortality rates are worse than those of its neighbouring countries and BRICS nations.

1418035383-447_Mortality-rates-2013-IMR-MMR-chartbuilder

As the British medical journal The Lancet wrote in an editorial on November 29, “This ingrained inequality has led to tacit acceptance of the caste system, which has created, among other challenges, a preventable epidemic of mortality among women and children.” In effect, irrespective of what changes are instituted at the top, they will not reach the masses if access to healthcare and medical services remains segregated by caste.

These three hurdles are further compounded by successive governments’ tendencies to confusion. On one hand, Prime Minister Narendra Modi promises more All India Institute Of Medical Science in the country and on the other cuts the health budget by $900 million. The United Progressive Alliance government before him managed to eradicate polio but let that pursuit overshadow that of full-immunisation, the rate of which has fallen in developed states like Tamil Nadu, Maharashtra, Haryana and Punjab.

Such equivocal measures are the product of the thinking that health is purely a biological concern, not influenced by understaffed training institutions, overzealous eradication drives, import-friendly regulations, inexplicable shortage of health inspectors or segregation by caste.