The Entitlement of Our Elites

An Indian diplomat to the US named Devyani Khobragade was arrested in New York on charges of forging visa documents for her house maid, making the maid work long hours, and not paying the agreed upon sum of money. The maid had filed the complaint. Ms. Kobragade lamented that she was handcuffed, strip-searched and treated like a "common criminal." The U.S. prosecutor involved in the case, Mr. Preet Bharara, defended that there was no violation of protocol. He asserted, "Is it for U.S. prosecutors to look the other way, ignore the law and the civil rights of victims or is it the responsibility of the diplomats and consular officers and their government to make sure the law is observed?"

The fury the arrest incited in India was astounding. The prime minister and the parliament expressed outrage against the arrest of the diplomat. They removed security barricade from the U.S. embassy, expelled a consular, blocked the flow of whiskey for the embassy staff (one has to wonder what incites creativity in Indians!). There were editorials condemning the U.S. There were enthusiastic flag burners in the street. Media reported that the maid's family was threatened. Even our own fierce proletariat Prachanda's foreign relations advisor penned an OpEd lamenting how was it possible for the poor diplomats to survive with a maid on meager USD 2000 per month if they pay the minimum wage demanded by the law of the land  (my simple advise to the advisor in such a profound dilemma would have been: not own a maid). 

I was flabbergasted by the Indian response. A person who had abused a vulnerable, powerless worker, lied to the authorities, was arrested following the law of the land following the complaint of the victim. And the whole country was vouching for the person who had committed the crime!

She howled, she was treated like a "common criminal." And the country said, "yes she is no common criminal, she needs to be treated special!" 

"It is a matter of our national pride, the pride of our mother country, the pride of our flag, the pride of our government and parliament, brothers and sisters!" said the Indians. "Yes!" everyone said. 

The crime vanquished from the conversation. Why bother what the grievances of the maid might be? The whole focus turned on: why was Ms. Khobragade treated like a "common criminal?" The turning of this beyond-common elite to a common was what hurt the conscience of the elite India. 

That is the entitlement of the elites of these regions. They have been so used to trampling over the rights, dignity and conscience of the powerless that if they are told otherwise they feel out of space. As if the reality has been distorted. I had learnt about it a little while back at smaller scales seeing our "Sirs" at public institutions. But I had never imagined that this can play out at the national scale as well. While at the smaller scales the tools of chauvinism are "insider"/"outsider", "senior"/"junior", "obedient"/"non-obedient", the tool at these national levels seem to be that of unreasoned nationalistic pride. 

In this perverse reality, countless of her citizens end up working in extreme conditions in middle east, her daughters and sisters raped and abused with none to voice the agony, her children denied basic dignity. Where is that diplomatic muscle where it is really needed? Where is that diplomatic muscle when it concerns the powerless? 

Dr. KC's Crusade

A paranoid schizophrenic man opened a fire in a public gathering of US congresswoman Gabrielle Giffords in Arizona in 2011. Six persons died, several were injured. Ms. Giffords was shot in the head; the bullet passed through her brain. She received immediate medical care and was operated emergently. She has made a remarkable functional recovery.

Dr. Peter Rhee, a trauma neurosurgeon who operated on Ms. Giffords took up the stage daily to update the press and the nation about her progress. However, he was an unconventional (almost exotic) character on the television news screen. Some people found his character to be even abrasive. Bottom line: this was a character not polished with the etiquettes of public speaking. He knew his trade; he had outcomes to support that but not the finesse of television talks.

We are also seeing our Nepali doctors on television screen on an almost regular basis now. There is a distinct difference of our doctors from Dr. Rhee. Their conversations on television screen are impeccable. They speak in language totally indistinguishable from that of our politicians or bureaucrats. There is a certain ease, smoothness and a natural flow. It is impressive!

**********************************************************************************************

As a 16-year-old boy, when I first read “Satyagraha in South Africa” by Gandhi, a knot formed inside my throat, my stomach churned, and tears poured out ceaselessly from my eyes at some point in the book. A burly pathan had thrashed Gandhi, bloodying him, because he had made a compromise with the rulers. A heartbreaking agony seeped inside me upon learning this harmless creature being beaten senselessly. I wanted to rather receive the beating, if I could, to spare this saintly man.

Perhaps that was the power of Gandhi’s personal character that formed the foundation of his non-violent movement. People felt Gandhi’s pain as their own. The sheer passion evolved into a massive movement with means revolving around self-sacrifice. Indians succeeded in ending the imperial British rule.

Lately, we have seen revival of similar means in our region. In India, a saintly man named Anna Hazare challenged the central government to address corruption and a new party called Aam Admi Party (AAP) blessed by Mr. Hazare came into power in Delhi. In Nepal, an orthopedic surgeon Dr. Govinda KC has been using hunger strike to address political issues plaguing his institution- Institute of Medicine (IOM).  AAP is aiming to change Delhi government so that it serves the people. Dr. KC is aiming to change IOM so that it is a better institution. These movements gathered steam based on distinctive personal characters of their leaders, especially their demonstrated track record of self-sacrifice. Their personal characters have touched the chords of people’s heart. Perhaps similar to how Gandhi’s character had. However, I feel, there is a distinct difference in the struggles that Gandhi pursued and what these folks are pursuing. Gandhi’s was of justice, theirs is of building institutions. So we should ask: Is it likely to succeed?

AAP’s ascendency to the throne of Delhi government was dramatic and filled with drumbeats of radical change. But looking from surface now, their activity has turned into a circus.  We have no idea if the end result is going to make any difference in peoples’ lives the aspirations of which had buoyed AAP to the power. I have no in depth knowledge of Indian politics and I would like to leave it there. But I would like dwell a little bit more on Dr. KC.

Dr. KC is known to have a distinct personal character. He is single. He lives a very simple life sustained by sole salary from IOM. He abhors private practice and earning extra money. He spends long hours in patient care. He travels to remote areas of Nepal on his own to care for sick people. He even travels overseas in disaster struck areas to offer services for free. This compelling personality seems to have touched the hearts of people. When he staged hunger strike recently, the passion people had for him was apparent. The doctors closed outpatient services in majority of the public hospitals throughout the country, there were parallel hunger strikes in solidarity with Dr. KC, there were mass resignations from doctors, news channels had the hunger strike as top story for several days and the government heads had to scramble to address the demands this doctor had placed. After 14 days, the hunger strike ended with an agreement. It has been a few weeks since that agreement. Now, Dr. KC is back to hunger strike because the government has not implemented the agreement.

At the crux of Dr. KC’s struggle is the intent to have IOM as an autonomous institution protected from the savagery of political beasts that have incinerated a possibility of a decent society; although the language of his demands also includes many other issues pertaining to the overall health care of the country.  If the media reports are true, the extent of shameless savagery politicians, corrupt bureaucrats in government and officials at Tribhuvan University have exhibited in pursuing their interests is extraordinarily disgusting. In that light Dr. KC’s noble struggle is truly very welcome. And his means of using his moral connection with other people brought together by the influence of his extraordinary personal characteristic is praise worthy. However, before we get swept away with this inspiring movement, it is important that we ask if it is likely to achieve the end results.

What are those end results?

Based on the demands set by Dr. KC, it seems to be achievement of autonomy of IOM, barring permit to open up new medical schools (where there is allegedly a huge bribery going on under the table to get approvals) and holding corrupt people in the system accountable. These are clear demands that are possibly achievable by the means Dr. KC is using.

However, it would be a mistake to pin too much hope on the dream of having a better IOM or national health care and health education system even if these demands were fulfilled. The real end results that the public institutions have to deliver is: accessible, quality health care and manpower trained to deliver such health care in responsible manner to dignified citizens.

I am afraid, the top-down structural change that Dr. KC is striving to bring about has to be met with bottom-up institutional changes to succeed in achieving the ultimate goal. And, I am afraid, his struggle hardly acknowledges that component. The political component can rile up passions because it is so dramatic. But the mundane day-to-day functioning of patient care where every patient interaction is weighed in terms of fairness, justice, appropriateness, quality and dignity is too banal, and too tying down. Holding everyone in the system accountable to high standards of ethics and integrity in patient care is too tedious. Our public institutions have considered those aspects dispensable. This was all too apparent in Dr. KC’s 14-day hunger strike. Outpatient clinics were closed, patients admitted to the hospital for surgery were discharged. The doctors conducted clinics in open tents in some public grounds. It was a mockery to the plight and dignity of sick individuals. They deprived sick patients of care or threw them out of their care and to top it off rounded up a drama under the tents. These doctors’ insensitivity to patients needs demonstrated during these protests speaks of a larger problem in everyday functioning of these institutions. That is how they are used to treating patients, that is how these institutions have allowed them to treat patients and it’s just natural for them to behave so. That is the component Dr. KC’s struggle will not address. And Dr. KC’s political achievement will be meaningless without the corresponding changes in the intrainstitutional behavior.  The same forces that are abusing the system now will find ways to corrupt the system in the new setup unless the institution has that corresponding bottom-up changes. It will just force them to use newer tactics.  Dr. KC will have to continue his hunger strike forever. Would it be more fruitful if the man of such integrity use more creative ways to build institutions that would care for patients than doggedly swim against the tide that will only be changed by collective transformation of this society at peoples’ level and perhaps at intra-institutional level?

********************************************************************************************

Being a doctor is a political job (Virchow would convince you on this). We want our doctors to be political. But there is succinct distinction we have to make. Using prevailing political language is not equal to the political cause that the doctors should pursue. Our political language concerns the interests of our patients that are connected to the larger society. This language has connection to issues like justice to our patients, fairness, ensured access to health care, dignity, and quality of care. The further our conversations go from these, we have to ask ourselves: are we embarking on a different turf? That turf might still be extremely valuable. But we have to get out of the illusion that it is the only thing holding up from building our institutions.