Saturday, April 07, 2018

Mucous Cyst Rx

"Its just a local trauma..."
"No, its a bacterial wart! be careful, it infectious...certainly needs a surgery and biopsy..."
"Oh, just a simple mucous cyst!"

Two months, four doctors and three hospitals and many thousand rupees later, we have gained a few insights into the way in which our medical system works. It give you a glimpse of how private medical care is designed to make a mountain out of a molehill, to scare and fleece the gullible.

Two months ago, our son Aki got a cut on his upper lip which, instead of healing, developed into an eruption. Flesh etruded out of the cut which bled profusely from time to time. One day it would seem to be healing with a black scab but return to a a fleshy, bleeding nodule the very next. About 10 days after it showed no signs of healing, we took him to a doctor at the nearby Jaypee Hosptital. The pediatrician said it was just a "local trauma" and prescribed a  an anti-inflamatory syrup.

Aki found the syrup tasty but it nothing to reduce the eruption, or the bleeding. So off we went for a second opinion, to pediatrician at Patparganj, one strongly recommended by doctor-friends. The clinic was crowded and, from the number of vaccine adverts on the walls, quite popular with pharma companies as well. The doctor here came through a fair, honest, consciencious physician. "This looks like a wart", he said, "It needs to be surgically is just an Out Patient (OP) procedure in any government hospital, but given the crowds, you won't be seen unless you know somebody personally. If you go to any private hosptial, make sure you get the estimates clearly, in writing, before you get the child admitted". He also graciously returned - to our amazement - his consultancy fees (INR500) because, in his words, "I only advised you to go elsewhere." 

Next stop, Max Hospital. Here we got to meet our first pediatric surgeon. One look at Aki's lip, and he declared that it was "mucous cyst". Pulling our a couple of blank sheets, he explained in detail how it developed. "Sometimes, the process of healing ends up blocking the flow of mucus cells...and instead of keeping the lip surface moist, they end up discharging mucus under the skin. This develops into a cyst which ruptures and bleeds easily." Surgery, apparently, was the only way to get the cyst removed.

How much would surgery cost? Well, the answer depends on whether or not you have a mediclaim insurance cover. If you do, then it would cost about INR 25,000 if you got it done at Max Hospital. The cost of booking an operation theatre, anaesthesia specialists and a days' stay at the hospital, we were told, made a relatively simple procedure expensive. 

Would this be defenitely covered under mediclaim? Guys at the billing office were not so sure. "Lets see", they said, "We will submit all the papers and then know in a couple of days". Not quite reassuring.

So now we went for fourth opinion with a surgeon at Kailash Hospital, Noida. The diagnosis at Max was reconfirmed. This certainly was a mucus cyst that needed to be 'surgically excised, or cauterized'. The cost was a couple of thousands less but, given the crowds at this hospital, nobody wanted to an operation date, or the insurance coverage.

Back at Jaypee Hospital, the feedback from the billing office was the same. The procedure would cost not less than INR 25,000, which included no less than INR 8000 for 'micellaneous consumables'! The cost of the biopsy, of course, would be extra.

Since none of the pediatric surgeons said that it was emergency procedure, we thought about it for a couple of days, checked with other hospital, and settled for a surgery at Felix Hospital. This was the only place were we met a pediatric surgeon who inspired confidence in us with his surgery-as-last-resort approach. This was the also only hospital that had an OT readily available, did not insist on conning insurance companies and came up with surgery cost estimates at INR 5500. The only down side at this hospital was that they charged thrice the amount for consultancy fees for pediatric surgeons, compared to far more reputed hospitals. 

Anyway, sometimes when all is not so well also ends well. A supposedly common medical condition was misdiagnosed, received inflated cost estimates for the surgery, and was finally sorted out for one-fifth the estimates. One thing is clear, the nexus between private private, medical insurance companies, and TPAs is designed to fleece patients - especially those who may not have the luxury of time to seek a fair deal.


- Oral mucocele -

Thursday, March 22, 2018

Young India - Unsatisfied, Unscrupulous, Unstoppable

"Where you stand depends on where you sit" - Mile's Law

Over the past two weeks I have come across two views on where India is headed, both seem to contradict each other but at the same time, pointing to a common direction while reiterating Mile's Law.

The first was an Explained session organised by the Indian Express at New Delhi where Manish Sabharwal, the chairman of TeamLease spoke of great business opportunities in the India, while the second one was book by Snigdha Poonam titled, "Dreamers".

Sabharwal was amazingly optimistic and eloquent on the direction in which India was headed. Where most liberals saw clouds of doom and gloom, he saw opportunties etched in the sliver linings. Sample these facts and figures -

- Good Times Ahead: 50% of India's labor force is engaged in agriculture which contributes just 13% of GDP, while 0.7% of the workforce is into ITES which contributes 9% of GDP! With more than 600 international companies setting up captive IT centres in India, the workforce of 3.5 million in ITES is set to double over the next 10 years.
- "Cascading Regime Change": We are already seeing the synergystic impact of recent reforms (GST + RERA + DeMo). Before GST there were only 7 million enterprises registered for indirect tax. Now there are 10.5 million -- a 50% increase in just eight months!

Sabharwal's optimism as the leader of one of the largest employers in India contrasted with that of the journalist Snigdha Poonam who saw the great mismatch between aspirations of millions of young Indians, and harsh ground realities.

If you saw a pop-up on your screen warning you of an IRS investigation in USA or a virus in your laptop/PC/mobile, chances are that you are about to be scammed by an Indian. It seems there are hundreds of call centers in the obscure byelanes of urban India, using desperate job-seekers to con the most vulnerable people across the world --  elderly pensioners, single mothers struggling to make ends meet and all those who are already intimidated by technology.
According to Poonam: "Like it or not, young India is what it is - unsatisfied, unscrupulous, unstoppable. Few young Indians had a clear sense of right and wrong: fewer gave a damn about it. 
The idea of personal benefit over public good isn't owned by them, however. It is at the core of India's value system. Sure, some young Indians will cheat their way to their dreams, but they don't see how they are different from anyone in the news - politicians, businessmen, celebreties..."
Sabharwal's TeamLease claims to have hired someone for every 5 minutes in the last few years and provided employment to more than 1.2 million since 2002. And yet, he also admits that his hiring funnel is very narrow - out of every hundred applicants, less than 5 are hired, trained and placed in various companies.

So there you are - the desperation and angst Poonam sees in the 95 who got rejected is quite different from the optimism of those who did. The way you look at the future depends completely on where you stand.


* Explained by Indian Express -

* Reviews:

Saturday, March 10, 2018

Aadhaar - Biometric Mismatch

Last week I found myself in a bit of a fix while trying to book a ride back home late at night.
Standing on a lonely roadside waiting for a confirmation on my Uber ride, I found that I no money to pay for it - there was no cash in my pocket, and my e-wallet account balance was below the minimum INR 350.

My account with Uber is linked to PayTM, a popular e-wallet platform in India. Uber gave me two options for topping up - through my credit-card or directly through PayTM. The latter had been an easier process but this hit a wall with the message which said that my account was not yet KYC compliant.

Know Your Customer (KYC) is now compulsary for all e-wallet accounts as per the new rules set by the central bank. Introduced with the objective of reducing misuse and money-laundering, KYC requires submission of id proof -  details of Passport, Tax PAN or the Adhaar universial id number.  I was under the impression that Adhaar was the fastest way of fulfilling KYC norms. I had done it earlier for my bank accounts and for a JIO mobile connection. It had taken just a few minutes to get an online confirmation.

However, the process was quite different for the PayTM. As soon as I sent my 16-digit number, I got a message saying that a PayTM representative come an meet me personally for a confirmation. A confirmation? Why is additional confirmation needed when, according to UIDAI's own procedures, the number could be used to confirm my identity with their central database? Anyway, since there was no hope of completing the KYC standing by the roadside at night, I went back to Uber and transferred some money to my PayTM account using my credit card.

A few days later, and after a series of SMSs, a representative of PayTM's "partner" turned up at my door with portable fingerprint scanner plugged into his mobile phone. He passed me his mobile and told me to type in my Adhaar number. Soon I got a message on my mobile with a code and a URL with the message - "By providing this code to our agent, you agree to become a full KYC customer of PayTM Payments Bank and confirm acceptance." You have no time to check the fine-print so the agent gets his code.

After this, a mouse-like device is used to scan my thumb-prints. One by one, the scanner moves from my thumb, to the pointer and index, until all 10 fingerprints are covered. For each and every scan he gets a message (from where? UIDAI?) saying that all the authentications had failed!

The look of amazement on my face prompted the agent to console me - "Aise hota reha hai...fingerprint badal jaate hei" (This keeps happening, fingerprints change over time). WTF?? I had heard about farm workers losing their fingerprints to hard labour but my fingers were anything but callused, or even unclean!

How can UIDAI authentications fail in urban areas? A quick internet search reveals that mine is not an isolated case. While authentication failures have been quite common on rural areas - due to incorrectly captured fingerprints, poor internet connectivity or a change in biometric details because of old age or wear and tear - it is now increasingly common in urban areas as well.

The Adhaar UID is no doubt backed by the laws of probablity and complex algorithms but this experience has placed me firmly in the ranks of the Adhaar skeptics. Failing to get an Uber taxi ride due to an Adhaar biometric failure hardly makes a difference to me, but to think that millions depends on this flawed system for their rations is just unexcusable.

Other Unanswered Questions:

* Now that the private sub-contractor to PayTM has all my fingerprints scanned and saved, what are the chances of misuse?


* Scroll on KYC problems -
* How to link PayTM with Adhaar -
* Fingerprint authentication failure -
* Medianama rebuttal to N.Nilekani's claims -

Friday, January 12, 2018

Jaipur, 1727

"Where do the poor in your city live?
Are they consigned to shanties and ghettos, far from the 'gated communities', 
or do they share a common, egalitarian space?"

Earlier this week, I found myself at IHC, a refugee trying to escape the evening traffic, looking for something worthwhile do until it was safer to drive back home. On the boards was a talk titled, "Architecture and Society Series: Future City Jaipur". It was apparently part of a series initiated by M.N. Ashish Ganju, and the speaker who posed these questions was Sudhanshu Mukherjee, an architect who thought that city planning in 1600's was a lot better than it is today.

Having visited and stayed in Jaipur numerous times, this did seem like a tall claim - until the speaker explained how the city came into being. In the early 1700s North India was in turmoil - the Mughals had weakened considerably and Raja Jai Singh thought it was an opportune time to build a new city which would attract businesses away from Delhi, Agra and Mathura, along an alternate route to the ports of Gujarat. Like any modern SEZ, the city of Jaipur offered numerous sops and incentives to traders who were willing to relocate to the new city.

The city was conceived as a nine-box grid, aligned not only to the principles of Vaastu-Shastra, but also the existing temples to the Surya and Krishna/Vishnu. While common infrastructure and services were provided by the state, each Mohalla or quarter was allowed to design living spaces as they wished, after the plans were duly approved by the chief city planner, a Bengali named Vidyadhar Bhattacharya.

The advantage of this flexible planning was that it integrated citizens from various economic and social strata into common living spaces. This, in turn, fostered a sense of belonging and an egalitarian sense of solidarity amongst various communities in the city.  This approach to city planning was later abandoned in favour of Western style grids that separated living and working spaces, in creating cities like Chandigarh and Bhubaneswar that end up looking "more like army cantonments than bustling metropolises; cities built for automobiles rather than human beings".

It seems there have been attempts to revive this approach, such as Norman Foster's Masdar City in Dubai which aims to be a "a mixed-use, low-rise, high-density development" with an emphasis on pubic transportation. Another example is Khuda-Ki-Basti (Hyderabad, Pakistan), and Incremental Development Plan which won the Aga Khan Award for Architecture in 1995.

As one of the few non-architects attending the lecture, I was struck by the pessimism of all the city planners present (were most of them Bengalis?). It also brought out the disconnect and the turf-wars going on between those who were teaching (mostly at SPA, Delhi), and those running their own studios.

In a hall that seemed full of articulate, long-winded experts, if there was one person who made an impression, it was the elderly Ashish Ganju. A practicing, teaching architect who had been staying for the past 18 years in Aya Nagar, a crowded village wedged between Delhi and Gurgaon, he seemed to be the only one walking the talk!

References & Links
* Book - Jain, Kulbhushan(): Indian City in the Arid West -
* SlideShare -
* Norman Foster's Masdar City, Abu Dhabi -
* Khuda-Ki-Basti, Hyderabad, Pakisan -

More Qs:

* How did Vidyadhar Bhattacharya end up in Jaipur? Is there a link between Jai Singh's tenure as Akbar's Subedar of Bengal, and his presence in the desert kingdom?

* In 1739, within a decade of Jaipur coming into being, the Persian marauder, Nadir Shah plundered what remained of Mughal Delhi. In Delhi alone, he is recorded to have massacred over 20,000 people. How many of the survivors ended up in Jaipur?