Monday, February 2, 2009

The sirens are calling!!

In the rather excellent readings this week, I discovered many theories, the postulates and positions of which I have often discussed but not the names. An interesting one is the "Dependency theory". The theory posits that Euroean development was predicated by the under development of the non-European world (Peet and Harwick, 1999). Certainly, the theory holds water if we trace the development of the world since the renaissance, the emergence of the industrial revolution, and parallely the enlightenment. Many scholars opined that this does not hold true anymore and Peet and Harwick mentioned the World Systems theory. But I would argue even today, the dependency theory can be applied to myriad contexts and used to explain them, though we have to replace the "European" with the "Western" and use the framework of even newer theories. Development aid is an area which offers itself to such critiques and indeed is rife with discrepancies and anachronisms. I was reminded of my time in a Price WaterHouse Coopers project where the Department of Foreign Investment (previously Overseas Development Assistance) of UK was funding power sector reforms in India. A macro view of the funding showed an interesting picture. Of the 100$ that was funded, more than 1/3 were disbursed through internationally appointed consultants (read PWC or KPMG), who charged a heavy management cost (read expatriate salaries, allowances) and so I was left wondering that where did all the money go and who developed really. I took solace in the fact that at least all the money to buy mineral water bottles and airconditioners was spent in Orissa!! The authors also mention that "the peripheral countries borrowed back their own surplus to finance "development schemes"". True, look at what is happening in Africa today and why the whole world from US to China and Japan are interested in providing aid to Africa including the sacred UN bodies. Scholars argue that these logic do not hold true anymore as all over the world more and more countries are now developed like the western world. This argument should lead us to question/ deconstruct and examine the notion of "development". What does this entail? and what does this mean or does it mean anything, to that community whom the entire world wants to develop? Whenever I hear a IFAD or World Bank funded project to build roads and infrastructure to develop rural hinterlands, I realize that the road to exploitation and misery is being built!! There should be no single answer or perspective to this but what is sorely required is engaging in these questions by the local educated government/ NGO workers/ media and a constant dialogue with the community. We cannot expect all of them to have read Marxism and related theories but one does not need that education to question these dominant paradigms. My grandmother never knew these things but her ideas, analyses and motivations were spot on. 

We discussed FGM/ FGC etc., in the first week, one such issue is SATI. I feel, in this search for exotica, the real issues get lost somewhere. Why have I not read issues of dowry and bride burning and bride torture, mistreatment of women since their birth, unequal treatment of women as described in Hindu, Musilm and Christian religious texts..where are they? I am more bothered about why a pregnant woman has to eat last in the house after all have eaten? Why the husband has to spend a portion of the meagre income on alcohol while the pregnant woman needs some vegetables or an egg? Why the mother has to store the better portions of the meals for her husband and sons? Why the sister had to forgo higher education opportunities as her younger brother has to go for engineering? Let us leave the exotica for those who enjoy them, the mundane life is elsewhere.

I have come across this CCC and cultural competency in numerous literature and classes here. Patient centered communication, attention to culture, constructs like listening, patience, attention, spend time, facial gestures, facilitative responses are important features in these models. In UNICEF education programs, we talked of child centered teaching, child friendly schools (even today this is a big concept!!). To my naive and impatient mind, there arose this question, "why are we making a mission statement out of the obvious?". I mean which place should be child friendly if not the school? Then, in the future we can advance objectives like "child friendly father", "child friendly mother" etc..Similarly, "patient friendly doctor/ physician", "patient centered communication". We have across time through our confabulations, dialogues, scholarships and search for the "newness"/ "theories"/"models", gained this ability to make the basic duties and responsibilities of a profession a thing to achieve. My parents are doctors and I have spent at least 25 years of my life living with them in the same house!! I used to assist my father in his medical examinations when I was in school and college. He would do these cardiograms and I would be the fellow to apply gels to the patients and attach the instruments and clean the patient and the instrument after the examination. This paid my allowance!! This gave me an opportunity to be part of numerous doctor patient encounters. Apart from this I have always moved in the doctor/ physician circle and I always felt that listening, patience, judgement, caring, these are non-negotiable attributes of the practice. Even highly money minded, ill behaved doctors cure patients and have a good following. One could argue the CCC model in the US scenario where the patient pool is so diverse, but then the patient pools are diverse also in India (probably more so as per cultural practices..and the ubiquitous caste and numerous religious practices). The doctor is not spending enough time as he has to earn more money, the insurance model does not allow him to spend time, the doctor is not listening because of other factors. What I am hinting that applying these CCC models would not improve the situation here in US or elsewhere in similar diverse situations. We need to look at the larger structures, the hegemony that is dictating the interactions. I am yet to see the articulation of physicians/ hospital administrators and insurers on their opinion of the myriad cultural competency models. In this situation the words of Good (1995) are critical that we should look at integrating culture and political economy in our analyses. Good talks about biomedicine, but this lens is also critical in doctor-patient interactions, the clinical encounter. Quoting Good (1995), "this mode of inquiry important not only to uncover blatant interests, be they economic or cultural, that shape what is regarded as competence in clinical medicine today. Such an integrated approach also encourages us to examine the broader complexities (and messiness) of social interchanges that produce the culture of the clinic".

Its often that I get a feeling that in getting so much of education I am adding ropes to my already secured position on the should fall for the lure of sirens too!!


Steph said...

You are right, one does not need education to make statements like your grandma did. Usually the people that live under certain circumstances have the best idea of what's going on first hand. Unfortunately you do need money and therefore power to be part of the decision making process. If people don't change for the better from deep within, I am afraid I sometimes catch myself giving up, although that is really not how I usually do nor life my life...

Steph said...

More...we kind of took a similar stance on the CCC model, I am looking forward to discuss this in class tomorrow, because as much as it sounds nice, doctors do A) not have time or want to take time to get familiar with the with a concept or model like this and B) the system that dictates their professional life won't allow them to, unless they at least want to get some money out of it. And even a "good" doctor needs to survive.

On Sati, I agree, there is bigger fish to fry and I am sure cultural rites such as Sati are only the used as a starting point for discussion that are yielded towards completely different issues, such as even further marginalizing a country.

Raihan Jamil said...

This rocks: "Let us leave the exotica for those who enjoy them, the mundane life is elsewhere."