Affordable Care in Rural India

I just returned from India, where I visited Flame University (the name is derived from "Foundation for Liberal  and Management Education") in Pune.

At a meeting with Professor D.S. Rao, Provost and Dean of the Flame School of Business, I learned about Yeshasvini, a cooperative health insurance venture for farmers in the state of Karnataka. At the depressing moment where the new U.S. administration  is preparing to tear down President Obama's extension of health insurance to a wider population, it was heartening to learn about a program working to advance Obama's ideals by insuring the poorest of the Indian poor.

India does not have a tradition of paying for health care through insurance. The majority of health care is still paid for on an out-of-pocket basis. Even though costs are much lower than in the U.S., for the large population of rural poor, modern health care is unaffordable.

Yeshavini, started in 2003, offers a limited insurance package to members of rural farm cooperatives on a prepaid basis for less than $5 per year per insured person! The state of Karnataka matches some or all of the farmers' payments. Karnataka, approximately the size of Nebraska, has a population of 64 million. As of 2014-2015, 3.8 million were enrolledin Yeshasvini.

Yeshavini's mission is noble:

"To bring health care of International Standards within the reach of every cooperative farmer of Karnataka. We are committed to the achievement & maintenance of excellence in health care for the benefit of farmer cooperator."

Even in India, $10/ year cannot provide "health care of International Standards." The package is largely for surgical services at 550 participating hospitals. Non-surgical treatment for cancer and diabetes is  not covered. But hazards faced by farmers like snake bites. goring by bulls, and accidents involving agricultural machinery are.

From a U.S. perspective, Yeshasvini is best thought about as a "proof of concept." In 1969 when I first encountered the concept of prepaid health care delivered by the not-for-profit Harvard Community Health Plan to a defined population on a prepaid basis, I thought this was the right way to provide modern health care. I still do. I joined the group in 1975, and while I ended my practice in 2008, I still get my own  care from the group and I work with it on establishing its new ethics program.

Somewhere between the pared-down Yeshasvini program in Karnataka that is affordable to poor farmers but covers too little and the super-comprehensive U.S. programs that cover too much and are a stretch for all but the wealthiest, is the golden mean of health care. But Yeshasvini supports the view that health care should be (a) population oriented, (b) prepaid, and (c) not-for-profit.

That's a perspective likely to come under attack from the newly installed Republican administration!

Drug-Resistant TB and a Physician Hero in India

Today's New York Times described Dr. Zarir Udwadia's campaign against drug-resistant TB. He is earning well-deserved international respect.

Dr. Udwadia is a pulmonologist in Mumbai. He did his medical training in Mumbai and Scotland. When he returned to Mumbai in 1991 he followed his pulmonologist father in starting a private practice. But he wasn't busy enough, and to use his knowledge he started a free clinic for patients with TB. It's now the busiest clinic at his hospital.

In 2011 Dr. Udwadia published a letter describing four patients whose TB infection was resistant to all antibiotics currently available in India. The Indian government's initial response was to attack the messenger, not to respond to the message. But Dr. Udwadia refused to be silenced, and brought the government to recognizing and responding to the medical crisis. The government now pays for drugs that were not subsidized in 2011.

I'm currently teaching medical students who are going into their first clinical rotations, and we've been talking about the patient-physician relationship. From that perspective I was especially moved by this passage:

The tall, lean doctor with a halo of black hair refuses to wear a mask to protect himself, even though his wife says he does worry about contracting TB. “How can you connect to a patient that way?” he asks. Instead, he leaves open his window so there is good air circulation, which reduces the chances of infection.

In the jargon of ethics, his actions are "supererogatory" - morally admirable but above and beyond what is reasonable to expect. If I were advising Dr. Udwadia, I would encourage him to protect himself to ensure that he continues to be available for his ministry to the poor. But his commitment to making a real human connection with his patients is in the best tradition of medicine and the spirit of Mahatma Gandhi.

Here are the closing paragraphs from the article:

When Mrs. Sheikh, a tiny woman wearing a salwar kameez, showed up for her recent checkup, Dr. Udwadia grinned and reached across the table to shake her hand, unable to contain his excitement as he reviewed her tests. They were negative for TB for the third successive year.

Her lungs are so scarred from the disease that she becomes breathless after walking several steps, but she says she is grateful to be alive. She takes a two-day train ride from her hometown in northern India to Mumbai every six months for a checkup.

“I know it sounds like a cliché, but these times are what I live for,” he says. “In India, all patients tell the doctor, ‘You saved my life,’ but with Rahima Sheikh, I know it’s really true.”

 When I see the brilliant, idealistic young medical students next week, I'll hope to convey some of the values that Dr. Udwadiah evinces so powerfully!

The ethics of writing about children with mental illness

I was recently asked about the ethics of writing about children and adolescents with mental illness. I've edited the actual question to preserve privacy:

I've been asked to consider writing a book about a parent and a mentally ill child. I'm convinced that the story needs to be told; but I'm not sure how to do it ethically. We don't want to re-traumatize the child, who is unable to give informed consent to interviews or to decide about making the story public, and probably won't be able to give informed consent even after reaching the age of majority.

We want to be responsible -- to respect the child's privacy and to do no harm. But we want to validate the experiences of other parents who are living through this with their children; to improve public understanding of the condition; and to advocate for the kids and families who are struggling. They're suffering in silence right now.

Because of the nature of the disorder and the behaviors that children with the condition display, the "commercial" literature that's available pushes the boundaries of good journalism. So much is changed to protect the children's privacy that it damages the credibility of the writing. But it's impossible to guarantee privacy if we write honestly. If we describe even one event exactly as it happened, SOMEBODY is going to recognize the child.

What an important question this is! It poses a fundamental "good vs good" conflict: the value that the story might have for other parents and folks who make policy relevant to the child's condition vs the child's right to privacy and protection as a minor.

Apart from how individuals will weigh these values, cultures themselves vary. Many years ago I joined a psychiatrist in India at a session in a clinic serving the poor. I knew him to be a kind and considerate man of great personal and professional integrity. He asked patients who spoke English to "talk with the doctor who is visiting with me from the United States." After an extended discussion with a couple I asked my host if it would be acceptable for me to ask for their permission to take a photograph of them. To my astonishment, my host responded - "just go ahead - you don't need to ask permission." (I wasn't comfortable doing this and put aside the photograph idea.) Subsequently I experienced the same cultural perspective in settings where I was the only Caucasian - people sometimes took photographs of me as an interesting phenomenon.

My reaction to the question is unambiguous. For me, the child's interests come first. I advised writing a well-disguised version of the story that met my rule of thumb - the child's neighbors, teachers, and friends shouldn't recognize who the story is about, and the child, now or at an older age should feel respected by the way she or he is written about. That level of disguise may diminish the value of the story for other parents or policy makers, but in my view that's the correct trade off among values.


On World AIDS Day in 2005 I was in Madurai, India. A man disguised as a giant condom was circulating in the crowd. When I pointed my camera at him he indicated that I should stand next to him and be part of the photo. Perhaps he felt that I should collaborate with him and not objectify him. FYI, here's the photo:
 

Serving God in our Patients

In 2009 I had the privilege of spending two days at the Swami Vivekananda Hospital in Saragur, India. (See here for a post about my visit.) Since that visit I've followed a blog by Dr. R. Balasubramianiam ("Balu"), founder of the Swami Vivekananda Youth Movement, sponsor of the hospital.

In a recent post, Balu wrote about Dr Swaminath ("Swami"), a psychiatrist in Bangalore who has visited the Saragur hospital every month for fifteen years. Swami sees 35-40 patients at each visit. Along with colleagues, Swami founded Chittadhama, a refuge for homeless mentally ill. Balu visited Chittadhama, and wrote about it as follows:

Swami confided in me that he was concerned that Chittadhama be able to provide every person who came in looking for solace and treatment, with food to eat to their heart’s content. He was narrating how these people are misunderstood and consequently ill-treated by their families and society. Many of them go without baths for months and eat only when some kind-hearted soul gives them food...This is a place where one can give so much to people - people who will truly make us feel privileged and happy that we are given an opportunity to serve the God in them.

Although I'm a secular person in terms of theological beliefs, I regard health care as a calling, and Balu's comment about "serving the God" in one's patients resonated. I Googled Dr. Swaminath and found links to excellent articles in the Indian Journal of Psychiatry on doctor-patient communication, psychoeducation, "cinemadness," truth telling, and counterfeit drugs. I was struck by the overlap of our interests in ethics, clinical practice, and health policy.

Over the years I've thought a lot about where the health care "calling" comes from for those who do not base their calling on an explicit theology. I believe that being part of a community with a shared ethical commitment is part of the ground for a "non-theological" calling. To my understanding, Balu's concept of "serving God in our patients" is essentially the same as my belief that the right orientation towards our patients is the form of "love" that Martin Buber conceptualized as "I-Thou."

Internet and search engines create potential for a global moral community. I feel moral solidarity with Dr. Swaminath, a fellow psychiatrist who I will probably never meet.

Psychiatrists, God, and Lying

A psychiatrist in Texas submitted an important question to Randy Cohen's "The Ethicist" column today. I've taken the liberty of copying the question and Randy's response below, with my own comments in bold italics:

I am a psychiatrist who happens to be an atheist. Occasionally a patient asks me what religion I follow and, displeased by my answer, seeks another psychiatrist. I am a physician, not a priest. Religious beliefs seem as relevant to my profession as they are to an accountant’s. Nevertheless, candor sometimes costs me a patient. May I claim a belief in God to avoid damage to my credibility and business?

VAIDYANATH IYER, THE WOODLANDS, TEX.

To rephrase your question slightly: May you lie to a patient to initiate a relationship of trust? O.K., I’ve rephrased it totally and unflatteringly, but the answer — no — is provided by the American Psychiatric Association’s “Principles of Medical Ethics,” which requires you to be “honest in all professional interactions.” And rightly so.This is vintage Randy Cohen writing. His question brings out the "right answer" without being weighed down by tedious theorizing. And the quote from the APA shows that the profession agrees. But we should ask (a) what's going on when patients ask Dr. Iyer about his religion, (b) why honesty is so important in the patient-doctor relationship, and (c) what the wisest response is.

What you may do is decline to answer such questions. Glen O. Gabbard, a professor of psychiatry at Baylor College of Medicine, told me in an e-mail that “it is not dishonest to use restraint in responding to questions of a personal nature.” He added, “One can also inquire about the reasons for the question.” The patient’s reply might offer insights useful in treatment. Glen Gabbard is perhaps the most eminent clinical teacher in contemporary psychiatry. His advice, as usual, is spot on. Especially in psychiatry it's crucial for Dr. Iyer to know what patients are communicating about themselves when they ask him about his religion.

Many years ago I had a first meeting with a gay man in recovery from severe substance abuse problems. At the end of the appointment I said - "I've asked you a lot of questions. Do you have any questions for me?" He replied - "Just one. Are you gay and in recovery?" I responded - "If it's OK with you I won't answer directly. I'm not sure what form of treatment I'm going to recommend, and in some treatments it's best to explore questions like this, not to answer them directly." He said - "That's OK. I know the answer - it's 'yes.'" He felt comfortable with me and felt understood, which to him meant I must be gay and recovering with a history of substance abuse. (Neither was true, but the treatment went well.)

The patient’s question need not reflect mere prejudice but could express a desire for a psychiatrist whose personal experience will yield a deeper understanding of the patient. On such benign grounds, some women seek a female psychiatrist, some homosexuals a homosexual. But it is also true that you need not be a Presbyterian to effectively treat a Presbyterian. Even a gay female Presbyterian.

It's crucial to consider the context here. "Iyer" is typically a South Indian Hindu name, which leads me to guess that Dr. Iyer is of South Indian background.The Woodlands is an almost all white, upper middle class community near Houston. It's just a year since the Fort Hood killings, for which Dr. Nidal Hasan, a Muslim of Palestinian background, is the presumed killer. Some of Dr. Iyer's patients may be wondering if he is Muslim, which, sadly, is the focus of widespread prejudice. At an unconscious level they may fear that psychiatrists are not trustworthy and treatment will do them harm. Patients who feel good rapport with Dr. Iyer may tell themselves "he looks foreign, but I know he's really a good Christian, like me," much as my patient assumed I was gay and recovering from substance abuse.

And so you should respond courteously to such queries, answering those about your training and technique but not those you deem irrelevant to the work. Are you Jewish? A Republican? An opera buff? This demurral could cost you a patient or two, but so be it. A patient’s determination to make an unwise decision does not justify a doctor’s deceit.

I wish Randy had picked up on Dr. Iyer's comment "I am a physician, not a priest. Religious beliefs seem as relevant to my profession as they are to an accountant’s."

When I visited the Indian National Institute of Mental Health and Neuroscience in 1989, I was told that many rural Indians, but also educated urban dwellers, only consult a psychiatrist if religious practice - puja - hasn't relieved their symptoms. And in my clinical office I often felt that an anthropologist would see underlying structural similarities between medical practice and religious practice. The line between "priest" and physician" isn't as absolute as Dr. Iyer's question implies!

I think Dr. Iyer's comment about accountants is correct, but not in the way he intended it. Unless we're looking for an accountant to help us cheat, as Enron and its ilk did, the accountant's character matters a lot, just as it does for a physician. Accounting isn't just a matter of adding up numbers - it rests on decisions about how to deal with expectations about how we conduct our economic lives and meet expectations of the state (ultimately, our fellow citizens). If we only trust an accountant (or physician) who belongs to our own denomination (including the atheistic denomination) we'll miss out on some good ones and trust some bad ones. Dr. Iyer's patients are wrong to focus on his theological beliefs, but correct to be concerned about what kind of a human being he is!

(For an excellent film in which the name "Iyer" is central, see "Mr. and Mrs. Iyer."For previous posts about Randy Cohen, see here and here

The Medical Council of India Sets Tough Rules about Pharma

Rema Nagarajan, a journalist friend who writes for the Times of India, brought to my attention a recent ruling of the Medical Council of India about physician relationships with Pharma and other health sector industries. On paper at least, the ruling is very tough! The rules include:

• Physicians shall not accept any gifts whatsoever
  
• Physicians (and their families) shall not accept any paid travel, whether for CME or any other purpose
  
• Physicians shall not accept any "hospitality" (such as hotel accomodations)
  
• Physicians shall not accept any cash payments whatsoever
  
• Any research funding must come through institutions, subject to a range of regulations

India is an international target for drug trials, given the size of its population and the laxness of its human subjects protections. And, many physicians are struggling financially such that attendance at educational conferences, especially outside of the country, was essentially impossible for them, making them prey to the appeal of travel funds or gifts of office equipment.

Rules are one thing and enforcement is another. It's not yet clear what the consequences of violation will be. But the Medical Council has put a strong stake in the ground, for which it deserves international recognition.

(For previous posts about pharmaceutical ethics in India see here, here, here and here. For Rema Nagarajan's article in the Times of India see here.)

What Can Medical Ethics Contribute to Health and Health Care in India?

Yesterday I attended a conference at Harvard Business School - "The Indian Growth Story: Sleeping Elephant or Roaring Tiger?" I've been thinking about what medical ethics can contribute to health and health care in India since spending the month of January there, and I thought I might learn some useful things at the conference. (See as well this previous post on ethics teaching in India.)

I wasn't disappointed.

Before the conference started I had coffee with a group of young India men - some still in business school and some in their first jobs. When I told them about my interest in medical ethics, one asked "is it true that before a person (or a country) is established there is no time for ethics; when you are established then you can think about ethics?"

I told them we have to address ethical questions at every phase of personal and societal development, but the questions and expectations are different at each phase. My hunch was that early on the key job is creating an "ethics infrastructure" that will support ethically admirable health system in a later phase.

Several speakers made reference to "jugaad," a Hindi word meaning inventiveness, cleverness and ability to get things done in unorthodox ways. When I looked up the term, here's what I found:

It’s like putting two spoons of turmeric powder into your radiator if you spring a small leak. It works, it will seal the leak. In Punjab, I have seen villagers buying an agricultural water pump at government subsidised rates, cannibalising some other parts from here and there, and turning it into a vehicle. These are jugaads.

The excellent panels and plenary talks described a vibrant economy with lots of opportunity for any of the ambitious and entrepreneurial young people at the gathering who wanted to return to India. Jugaad was a common theme - finding distinctive Indian ways of addressing problems and promoting development.

As I understand it, jugaad is an attitude and set of skills that in themselves are morally neutral. In the U.S. Enron specialized in jugaad - ingenious but virulently unethical and often criminal innovations. But speakers like Dr. Pradip Kumar Sarmah, founder and executive director of the Rickshaw Bank, an enterprise that (a) makes microloans to rickshaw pullers to enable them to own their own rickshaws and (b) has supported design research to develop a new and more efficient rickshaw model showed how jugaad can promote social justice.

In U.S. medical ethics education we tend to focus on ethical nuances and conundrums - like whether a particular patient's refusal of treatment reflects decisional competence and should be respected or doesn't meet the criteria for informed choice. From what my Indian friends tell me I infer that a case like this would be premature - the teaching task would be conveying the concept of informed consent itself and working with the question of whether and why patient preferences should be respected.

My current best guess is that the key pieces of "ethics infrastructure" to focus on are (1) informed consent, (2) research ethics, especially the ethics of clinical trials, which is a booming industry in India, and (3) strengthening the expectation that health professionals must consider population health and the common good as well as their own immediate practices.

The "Beggar's Song" in "Threepenny Opera" told us that some basics must take precedence over ethical niceties - "First feed the face, and then talk right from wrong...for even saintly folk, can act like sinners, unless they've had their customary dinners!" This was behind the question I was asked at the beginning of the day, with the implication that a concern with ethics is an impediment to development.

But I think the ancient rabbis got it right when they taught "Without sustenance there is no Torah (ethics); but without Torah, there is no sustenance." With enough skill at jugaad, ethics and development can go hand in hand!

Drug Trials in India - a Video Interview with Amar Jesani

Anyone interested in the ethics of clinical trials in developing countries should look at this five minute video of an interview with Amar Jesani, a leading human rights advocate in India.

Dr. Jesani, who I had the privilege of meeting with at the Center for Studies in Ethics and Rights in Mumbai during my recent trip to India, reports the prediction that in ten years one third of all clinical trials will be done in India. The primary reason is cost reduction - trials are 50% - 75% cheaper to do in India than in the U.S. And India's huge population means that there are enough patients with the condition being studied to conduct most trials.

According to Jesani it is easier to carry out trials in India because although there are laws that ostensibly protect patients, regulation is very lax. Poor patients are desperate for care and are typically subservient to their physicians. Government inspection and ethics committee oversight is week, and the regulatory process is subject to corruption. The picture he sketches is not pretty.

Jesani explains that he and his colleagues are fighting for three things. First, clinical trials done in developing countries should be relevant to their needs. Second, in the course of the trials there should be no human rights violations. Finally, if the trial is successful the drug should be available in the developing country at an affordable price.

The video is thoughtful and constructive. The comments it received are not. Here's the most printable one: "I have been conducting clinical trials around the world for 18 years. This video is a scam this doctor is a liar...This guy is probably trying to scam a few million from the drug companies in an extortion con."

In the last few years in the U.S. we've seen a rising crescendo of criticism of the ways the pharmaceutical industry has corrupted science and clinical judgment. The ethics of international drug trials will come next in this advocacy process. If the issues are new to you, have a look at the video.

Teaching Medical Ethics in India

During the four weeks I've just spent in India (I'm at the Amsterdam airport now, on my way home) I asked two questions about ethics and ethics education: 1) Can the field of medical ethics, which is so well established in the west, contribute to improving health in India? 2) Insofar as the answer is yes - how?

Medical ethics is not well developed as an academic field in India. To the best of my knowledge there are no medical school departments of ethics. Minimal curricular hours are devoted to the subject.

I believe that ethics education can make important contributions to health care systems and ultimately to health itself. But I formed this view in the U.S. In India I challenged myself with my favorite question - "so what?" So what that ethics education in India is rudimentary? What difference could more attention to ethics education make in a country with more than a billion people including a rural and urban population barely living at a subsistance level that is larger than the entire U.S.?

I was able to have a series of meetings with people who were generous with their time and thoughts. They delineated four major areas of concern:

1. Improving health status and access to care for the poor - both rural and urban. Several people feared that in its zeal for economic development the Indian government is starving the public sector and overly relying on a private health system. One described a vicious cycle in which as the public lost confidence in the poorly funded public system that loss of confidence was cited as justification for further reliance on private and for profit "solutions."

2. Dealing with environmental health hazards. As an example, yesterday's Times of India descibed staggeringly high levels of multiple drugs in the Andra Pradesh water supply - a result of dumping by pharmaceutical manufacturers. An activist physician stated "It's a global concern - European countries and the US are protecting their environment and importing the drugs at the cost of the people in developing countries." A village woman added -"When the local leaders come, we offer them water and they won't take it."

3. Addressing continuing stigma and ostracism of people living with HIV/AIDS. The National AIDS Control Organization (NACO) and its state branches and multiple NGOs have worked hard in this area, but stigma and ostracism continue to be major problems. (If you're interested in this area, the Yahoo AIDS India e-Forum is a great place to start.)

4. Responding to the torrent of clinical trials from the U.S. and Europe. India has an enormous population of poor people who have thus far been relatively easy to enroll in drug trials that are often poorly regulated (see here for a previous posting on this topic).

These aren't subtle or obscure issues. Like India itself - they're big. Does ethics education have anything of value to offer? I think it does.

If I were consulting to a medical school in India about establishing an ethics curriculum, here are three of the suggestions I would make:

1. I like to think of ethics in terms of three As - Analysis ("what is the right thing to do in this situation?"), Advocacy ("let's do the right thing"), and Administration ("what systems and procedures do we need to help the right thing happen?"). The analytic component , which is dominant in U.S. ethics education, would be less central at the start in India. The key goal of the program should be to encourage health professionals (and other stakeholders) to include responsibility for promoting population health as part of their professional identity, and to suggest ways in which they (whatever else they do) can (a) advocate for improved population health and (b) contribute to administrative measures that support positive actions.

2. Words in a lecture (a more central mode of teaching in India than in the U.S.) or on a page won't foster advocacy skills or administrative understanding. The new ethics education program should be guided by Albert Schweitzer's famous precept: "Example is not the main thing in influencing others - it is the only thing." Students should be exposed to health professionals who have found ways to put population health ideals into action. If the medical school were in proximity to the Vivekananda Memorial Hospital in Saragur, in the state of Karnataka, I would want them to meet with the staff I encountered there (see my posting on the Vivekananda hospital) and for interested students to work there, even for a short time.

3. Finally, I would want the program to be linked to an important area of population health in the local community. If the school was in Chennai, in the state of Tamil Nadu, where the headquarters of the Indian Network of People Living with HIV/AIDS, an NGO founded and run by HIV+ people, is located, learning about the difficulties HIV+ people - especially the poor - enounter in seeking work, accessing care, and maintaining ties with family and community, would be a rich learning opportunity. I would hope that faculty would not simply profess ethics but would put their professions into action, and take students with them in doing so.

Responding to Medical Mistakes in India

For anyone interested in (a) India and (b) medical ethics, (c) the Indian Journal of Medical Ethics (IJME), which is available online, is the key resource.

During my recent stay in Mumbai (I'm in Bhopal now) I met with Sandhya Srinivasan, the executive editor. I learned that IJME was born out of activism. In 1992 a group of reform-minded physicians contested the Maharashtra state medical council election on a platform of "ethical medical practice." The slate lost badly. But the reformers created a newsletter for discussion of ethical issues and promotion of ethical practice. Over time the newsletter became the IJME.

I am especially interested in how the interplay of modernization and tradition in Indian medicine affects ethical norms. By U.S. standards Indian physicians are on a pedestal. I was told that many of the poor see the doctor as "a God on earth." But at the same time western values embodied in concepts like informed consent, physician-patient collaboration, and open acknowledgment of medical mistakes are increasingly part of public discourse.

What happens when "physician as God on earth" meets "physician as collaborator"? The most recent issue of IJME provides a window onto this question.

Dr. Ashok Sinha, a private practitioner in Agartala, the capital of Tripura (a small northeastern state bordering on Bangladesh) discusses - in thoughtful and personal terms - how to respond to poor practice on the part of colleagues. Here are the first two paragraphs of his engaging commentary:

"One of the major ethical issues that I face very often in my practice is whether to criticise my colleagues or not. Complaints, criticism and condemnation lead to terrible consequences and never help anyone, they say. I am told that my colleagues are to be treated like my siblings and I should never criticise them in front of patients.

That seems logical enough. We may or may not agree with a particular diagnosis offered by fellow physicians, and it is not necessary that either of us would be right every time. But to criticise him or her in front of the patient would degrade the whole medical community. Even the patient would be in doubt about whom to trust. Moreover, very often this criticism is fuelled by competitive one-upmanship. Rather than bettering our performance to get ahead, we used the tactic of putting the other fellow down..."

Dr. Sinha reports that "sometimes I spoke out and made myself unpopular, and sometimes I did not, and hated myself for it." But his dominant ethical perspective is that "while we must have loyalty to the profession and the medical community, what about loyalty to patients?"

Dr. Sinha's discussion is followed by two commentaries. Ann Sommerville, head of ethics at the British Medical Association, argues that "in case individual integrity is not enough, doctors also have a duty to take action if they witness evidence of colleagues failing...lessons should be learned, future errors avoided and natural justice dispensed to patients who have been inadvertently harmed." Prabha Chandra, Professor of Psychiatry at the National Institute of Mental Health and Neuro Sciences in Bangalore, concurs. His emphasis, however, is on the need for a practical learning curve regarding how to talk with physicians and patients about mistakes.

The trio of articles strike me as precisely on target. The broad values of honesty with patients and professional responsibility for assessment of practice and self-regulation, do not appear to be culture-bound or limited in their relevance to the west. But values require practical implementation. There is currently very little teaching of medical ethics at medical schools in India, and professional societies do not have strong traditions of self-regulation. I expect the medical community to endorse Dr. Sinha's framework of values, but as Dr. Chandra points out, there is substantial research and skill-development to be done to put that framework into action.

Ethics at the Swami Vivekananda Hospital

I'm in Mysore, in the South Indian state of Karnataka, for eight days, at the Vivekananda Institute of Indian Studies. The Institute is part of a remarkable twenty five year old non-governmental organization - Swami Vivekananda Youth Movement (SVYM).

I visited for two days at the hospital the NGO runs in Saragur, a rural community forty miles southwest of Mysore. The visit provided a rich perspective on the ethics of health care and health organizations. I've organized my initial thoughts around two questions, both involving the concept of health care as a calling:

1. If health care is a calling, where does the call come from? Dr. R. Balasubramianiam ("Balu"), currently president of the NGO, led a group of medical students at Mysore Medical College who founded SVYM in 1984. Balu described how at 17 he was "ragged" so harshly by the senior students at the engineering college he had enrolled in that he decided not to go back. Since simply staying at home wasn't an option, to cover up the fact that he wasn't at school he started to spend the hours he would have been at the engineering college at an ashram, where he encountered the teachings of Swami Vivekananda (1863 - 1902) and was inspired by Vivekananda's vision of service to the rural poor and of making India an educated, healthy, harmonious society. Medicine, in the form of service to the rural poor, became his calling.

Balu's narration of his traumatic experience at the engineering college teaches one lesson about the origins of medical calling. It typically has strong personal roots. Virtually all of the physicians, nurses and other health care professionals who (a) I admire and (b) I know well enough to ask about their path to health care (c) cite meaningful personal origins of their calling. These vary tremendously, but have in common being intensely important to the individual.

Pictures of Swami Vivekananda and placards with his most quotable sayings are all around the hospital. When an associate of the NGO told me that he himself was an atheist I asked him "if Swami Vivekananda were here and heard you say that - what would he say?" The response was - "the Swami was an atheist himself - he thought that any god who allowed so much suffering didn't deserve to be worshipped. He taught that the religious spirit was shown in service, not in ritual practices."

Dr. Sridevi Seetharam, a physician deeply involved with medical ethics, explained that in Sanskrit terms, the gentleman I quoted in the previous paragraph was talking about the devotional path known as Karma Yoga - "selfless service to others in one's chosen profession or area of work." Vivekananda was Hindu by birth, but taught that all religions are in some sense "true." In addition to the personal origins of each person's calling to health care, the hospital's inspiration, Swami Vivekananda, and the ancient tradition of devotion through a Karma Yoga, which can be entirely non-sectarian and non-theistic, provides an external pillar for the calling.

In the U.S. people of faith can, if they choose, base their calling on their religious beliefs. But the kind of framework the doctrine of Karma Yoga provides, is not part of our secular ethos. The professionals I most admire act as if they were carrying out a devotional process, but if asked to explain the foundation that underlies their care giving, they're often at a loss to articulate it, or say something like "this may sound like a cliche but..."

2. How does calling manifest itself at the organizational level? My time at the Vivekananda Hospital was limited, but:

* The hospital and its outpatient clinic serve a rural population that includes tribal people who are only recently out of the forest. There is a huge social gap between many of the patients and the well educated professional staff. But the professionals evinced an interest in and warmth towards the people they serve that seemed more like love than technical "cultural competence." The physicians we spoke with evinced deep empathy with the patients. One manifestation of this empathy was creation of a strong role for "patient care managers" who come from the rural population and guide patients through their interaction with the care program in a side by side manner. Empathy is also manifested by providing free lodging for family members who cannot go back to their villages at night because there are no buses after 5:00 PM.

* Physicians were remarkably knowledgeable about traditional Ayurvedic treatment methods and Ayurvedic clinicians were part of the staff. Patients whose traditions and beliefs included Ayurveda had access to this approach in a way that was integrated with the allopathic services they received.

* A holistic view of health as involving more than medical relief of pathological states led the hospital staff to initiate a range of other activities including health and hygiene education in the villages, support for school improvement, and promotion of a clean water supply.

* Finally, and most remarkable from an American perspective, the hospital holds a twice a week non-sectarian prayer meeting attended by all of the staff and all of the patients. I was not present for a prayer meeting, and I do not see it as a format that would fit into a secular U.S. institution, but finding acceptable ways of recognizing the calling that all are participating in is a desirable path to follow.

A Mild Wrist Slap for Pharma in India

Last month, before coming to India (where I am now) I wrote about the drug marketing scene. The posting gave a link to an article in the Times of India that suggested to me that the Indian media were on the trail of the Pharma-Medicine story that is currently exploding in the U.S.

In Delhi I met with Rema Nagarajan, the reporter who wrote the Times of India story. Rema is well-informed about developments in the U.S., such as medical schools banning all gifts to medical students, house officers and faculty. Yesterday she had a followup article in the Times of India that suggests that the exposure of excessive pharmaceutical company influence over medical practice is heating up in India. India does not have the same level of consumer advocacy and consumer protection that has been developed in the U.S., but India is on its way in that direction.

Here are excerpts from Rema Nagarajan's article:

If you thought the government would crack the whip on pharmaceutical companies offering freebies to doctors for prescribing their products, think again. The department of pharmaceuticals has indeed taken note of the dubious practices reported by TOI on December 15, but in a surprisingly mild, almost apologetic tone.

Joint secretary Devendra Chaudhury wrote to the various associations of drug manufacturers on December 18 citing the TOI report, but the letter suggests he would be "grateful" if the associations acted on suggestions made by the department.

...The mild tone is despite the fact that the December 18 letter admits: "The allegations cannot be in any way treated as ethical and something that could be endorsed by society in general. This also puts the pharma industry in a bad light since the enhanced promotional expenditure of the pharmaceutical companies result in enhanced market price of the drugs, which has to be borne by the consumer."

Yet, it says the department would be "grateful if you (pharma associations) could kindly take action" on its suggestions and also take steps to "prevent such perception in the mind of the public and other bodies to obviate misuse of promotional expenditure" and to kindly "prevent allegations as well as media reports on this subject as have appeared".

The joint secretary says in the letter that "the matter being extremely sensitive and of great public importance I am constrained to write to you". With such a mild and apologetic tone from the government it is anyone's guess whether the pharma industry would feel the need to take any action.

Both the Organisation of Pharmaceutical Associations of India (OPPI) and the Indian Drug Manufacturers Association (IDMA) had released their own codes of conduct at the beginning of 2007. However, there is no single code applicable to all drug manufacturers, a fact that the letter points out. But again, this is followed up by a gentle nudge: "You may like to consider having such a code for your members"...

Establishing an ethical balance between medicine and commercialism in India will not be easy. Two very strong forces push against efforts to spotlight the problems and suggest solutions. Fist, there is tremendous trust in physicians, beyond what the profession deserves. (Rema quoted a Hindi saying in our discussion - "A doctor is like a God come down to earth.") Second, Pharma is a substantial component of the national thrust for rapid economic development. Successful enterprises aren't totally untouchable, but they are harder to tame than comparable enterprises in the U.S.

Preaching doesn't create an ethical health system. Public understanding of what constitutes good health system ethics and public demand for accountable performance are required. The media and political leaders are key "educators" for the public. I'll try to glean more about the societal learning process in India while I'm here.

Psychiatric Ethics in Mumbai

Because of (a) my clinical specialty (psychiatry) and (b) the fact that I'll be spending time in Mumbai next month, the headline "Psychiatrists work overtime with traumatized in Mumbai" in yesterday's Boston Globe caught my eye.

Here's the gist of the story:

"Since the gruesome Mumbai terrorist attacks, mental health specialists have been in big demand here.

But India, with 1.1 billion people, has only 4,000 psychiatrists, and efforts to provide adequate professional help for those traumatized by the rampage that left more than 170 dead and hundreds wounded is proving a daunting task.

Psychiatrists say it's not unusual to arrive at rural clinics and find 300 people waiting to see them. Each patient receives a scant few minutes of attention. Many give up and go in search of more traditional forms of assistance.

Evening "relaxation and breathing" workshops, for example, are being held in the immediate environs of the Chabad Jewish center that came under prolonged attack late last month and in other neighborhoods around Mumbai.

"We help ease people's tension through breathing techniques," said Ami Patel, an instructor with the Art of Living Foundation, which offers the sessions. "And people appreciate the feeling that someone cares."

...Mumbai psychiatrist Anukant Mittal is a case in point. He shuttles among city hospitals, suburban clinics, and primitive rural facilities, all part of a catchment area of 26 million people.

On any given day, Mittal sees patients ranging from chief executives of high-tech multinationals, who pay $50 per visit, to illiterate villagers wearing nothing but strips of cloth over their loins, and pay a subsidized 5-cent fee.

Rural residents sometimes turn instead to a shaman for help.

'You know very well they're going to go from your clinic to a witch doctor who will do black magic,' Mittal said. "So you have to say: 'I know you're going to need someone to exorcise this, but at the same time don't stop taking my medicine.'"

...Psychiatrists must grapple with their own anger, which can hamper their ability to help others. Recognizing this, hundreds of counseling professionals across India started an e-mail 'anger discussion group.'

'Psychiatrists are human, too, so we express our anger and try to heal ourselves,' said Harish Shetty, a social psychiatrist with Mumbai's Hiranandani Hospital.

'It's not always politically correct to admit anger, but in our epics, the Ramayana and Mahabharata, good kills evil,' Shetty said. 'It's part of our ethos.'"

For me, three aspects of the story exemplify admirable medical ethics.

First, Dr. Mittal's comment to his patient - "I know you're going to need someone to exorcise this, but at the same time don't stop taking my medicine" - embodies cultural awareness at its best. He recognizes his patient's beliefs, sees how they can be integrated with the treatment he is recommending, and presents a respectful synthesis of traditional healing and allopathic medicine.

Second, when "hundreds of counseling professionals across India started an e-mail 'anger discussion group'" we're seeing the kind of self awareness and self discipline that all health care professionals should apply. Whatever area of health care we're in, our attitudes and values are part of the clinical equation, and we have to do all we can to make sure they don't distort the care we offer.

Finally, Dr. Shetty's citing of the Ramayana and Mahabharata places health care where it belongs - in the context of wider culture. Practicing evidence-based medicine is a necessary part of excellent practice, but isn't sufficient in itself.

Health Care Rights in India and the U.S.

In yesterday's post on "Drug Marketing in Mumbai" I mentioned that I'm reading ethics literature from India in preparation for a visit I'll be making soon.

In the most recent issue of the Indian Journal of Medical Ethics, Dr. Helen Sheehan from the South Asia Studies Department at the University of Pennsylvania has a fascinating article on "Cancer, access to investigational drugs, and patient rights in the USA and India."

Dr. Sheehan tells a story from the U.S. (the Abigail Alliance case, which I discussed in "Access to Experimental Drugs - the Supreme Court Gets it Right") and a story from India (a cancer drug trial carried out at the Regional Cancer Center in Thiruvanathapuram in Kerala).

What's most striking in the story is that the rights at stake are polar opposites. Interestingly, both situations involve Johns Hopkins.

The Abigail Alliance case was brought on behalf of Abigail Burroughs, a young woman who contracted a rare head and neck cancer that did not respond to standard treatment. Her Johns Hopkins physician wanted to give her an experimental medication, not yet approved by the FDA. The legal action claimed a right for dying patients to have access to experimental drugs. The drug was not made available. Abigail died in 2001. The drug was subsequently approved by the FDA.

The posthumous appeal claimed a constitutional right to the drug, based on the fifth amendment guarantee that no person shall “be deprived of life, liberty, or property, without due process of law.” Patients in “last chance” situations, when standard treatment offers no hope – are facing death. The Abagail Alliance argued that by not facilitating access to drugs that have passed through Phase 1 trials, the FDA is depriving them of the right to opt for a potentially life-saving intervention. The District of Columbia Circuit Court ruled against the Alliance.

The situation at the Regional Cancer Center in Kerala involved trial of an experimental drug on 27 oral cancer patients from November 1999 to April 2000. The agent had only been tested in mice. Without approval from any IRB, a scientist from Johns Hopkins contracted with the Regional Cancer Center and brought the drug to India. In July 2001 a physician at the Regional Cancer Center blew the whistle on the study, claiming that no approval had been given and that the informed consent process was a sham. Johns Hopkins conducted its own investigation and concluded:

* The scientist was negligent for failing to submit a proposal for the clinical trial to a Johns Hopkins University institutional review board. Under university policy and federally mandated procedures, faculty experiments involving human subjects must have prior IRB approval, whether conducted in the United States or abroad.

* The trial did not meet Johns Hopkins standards for research with human subjects. For example, the committee found there was inadequate safety testing of the drugs in animals before they were injected into human patients. The committee also said that consent forms used to recruit patients for the study were inadequate.

* The scientist carried drugs used in the study to India without either an "investigative new drug" approval from the Food and Drug Administration or explicit FDA export permission.

* The scientist, without authority, signed several versions of a document committing the university to collaboration with the RCC.

In the U.S., the Abigail Alliance claimed (unsuccessfully) that the FDA regulations were too strict and abrogated Abigail's rights by preventing her and her physicians from protecting her against avoidable death. In India critics concluded that the Regional Cancer Center was too lax in its oversight of research, and that the drug trial abrogated participants' rights to adequate protection.

It isn't surprising that a country with strict research regulations (the U.S.) pushes drug research to sites where the regulation is more lax (such as India).
A New England Journal article discusses the risks to India as "A New Colonialism."

I hope we are in the process of seeing a global re-equilibration with regard to "rights" in health care. In the U.S. our expectations are excessive - as evidenced by our belief that we have a right to anything we or our doctors hope might provide benefit. In India, at least as seen by an outsider, expectations for what each individual deserves are too low, as evidenced by the way poor patients at the Regional Cancer Center were herded into a study. The disputed drug trial in India reflects the dark side of both countries - U.S. entitlement to join in the exploiting of poor citizens in India.

We owe thanks to the whistleblowers and journalists who give both countries opportunity to look in the mirror and see our failings.

Drug Marketing in Mumbai

I'll be in India for a month in 2009. One purpose of the trip is to learn about medical ethics education, ethics committees and the broad landscape of health system ethics, so I've been reading ethics literature from India itself. An article on "Drug promotional practices in Mumbai: a qualitative study" in the Indian Journal of Medical Ethics caught my attention.

The authors interviewed 15 senior executives from multinational (4) and Indian (11) drug companies, 25 pharmacists - 5 wholesalers and 20 retailers (5 attached to large hospitals and 5 stand alone shops each in rich, middle class and slum neighborhoods), 26 medical representatives from Indian (9) and multinational (27) companies, and 25 physicians - 13 GPs and 12 specialists who practiced in rich, middle class and slum neighborhoods.

Here are some excerpts from the article - with my comments in italics:

1. Information and brand reminders.
"Doctors stated that they received information on new drugs primarily through visits by MRs who use flip charts for this purpose. 'These flipcharts show the benefits of their drugs over the drugs of other companies. They also provide results of studies carried out by them on the drug's efficacy.' (general practitioner in slum)

According to the doctors, MRs rarely mentioned drug interactions and adverse reactions but they were otherwise generally satisfied with the information provided and accepted the MR's role. 'Everything is told in a precise way... medical representatives are well versed with their products and quite capable of answering the doctor's questions.' (senior general practitioner in middle-class neighbourhood)"

I saw this same system in action in 1989 when I spent a day with a psychiatrist in a public clinic. He let medical representatives join him when patients and their families (no one came in alone) were in the consulting room. As described in the 2007 article, the MRs pulled flip charts out of their valises and used them to demonstrate the virtues of their products.

"The doctors did state that MRs took up time that could be spent attending to patients and MRs were aware of this. "Doctors always perceive MRs' visits as an intrusion. Every minute taken up by the MR is time which could have been spent seeing patients and making money in the clinic. Often, MRs queue up early in the morning for doctors who allow only the first three MRs to see them." (from focus group discussion with medical representatives)"

The physicians I've spent time with in the public sector were treated like Gods. After the appointment patients touched the physician's shoe as a gesture of respect. It sounds as if the medical representatives had to come as supplicants in a similar fashion.

2. Incentives.
"Some MRs said incentives had become less cost-effective over the years as each company tried to offer more expensive gifts than the others. Incentives did not work to build a doctors' loyalty to a particular brand as all companies offered incentives. So they were now increasingly based on the prescriptions generated. Two doctors practising in slum areas showed printed handouts from a drug manufacturer giving targets and incentives to meet them. They were offered a cell phone handset for prescribing 1,000 tablets, an air cooler for prescribing 5,000 tablets and a motorcycle after 10,000 tablets were prescribed."

This direct "payment" for the number of pills of prescribed is a form of fee splitting. The practice should be seen as unambiguously unethical. There's no way a patient could, or should, trust the prescribing practices of a physician who receives direct payments for prescribing a specific medication.

"Another promotional practice was to finance educational programmes and conferences. Individual doctors' travel, stay and conference fees were also paid for by drug companies. Most doctors had no objection to such support and said they could not otherwise afford these meetings that they described as informative. A small minority felt that the lack of transparency in the funding of medical programmes by drug companies was unacceptable. Nearly half the doctors and all the MRs felt that over the past decade conferences had moved out academic college auditoria to five-star hotels which served lavish cocktail dinners, all with an accompanying increase in budgets."

All of the physicians I know who work in the public sector in India have difficulty paying for educational programs and conferences. If pharmaceutical companies gave money to a central body that administered a fund independently the practice would be acceptable. But paying for specified conferences where slanted presentations may be given is marketing, not education. And while we should not begrudge five-star hotel dinners or overseas conferences for hard working physicians - they deserve R&R - for drug companies give vacations and motorcycles it creates a clear conflict of interest for the physician.

"Drug companies stated that funding medical conferences had become less cost-effective; they suggested that doctors as a group had begun to pressurise pharmaceutical companies into financing their associations' programmes and would even boycott drug companies that did not give in to their demands. 'Things have got to such a stage now with doctors actually demanding sponsorship from companies. This year (an Indian drug company) had zero participation in (a specialist association's) conference. The company is now feeling the heat in the form of infrequent prescriptions.'(senior executive of an Indian drug company)"

This form of frontier capitalism would be funny if the problem weren't so serious. Drug companies give motorcycles for prescribing 10,000 pills. Professional societies boycott medications if the drug company doesn't pay up for their conferences. This is reciprocal bribery and strongarming!

3. Trade Practices.
"Retail chemists said that the multiplicity of brands made it difficult for them to stock all drugs and they risked being left with unsold stock. They therefore stocked the drugs of those companies which were promoted well both with the chemists as well as the doctors. Hence, it made sense for MRs to be consistent in promotion with doctors as well as chemists.

It was also reported by drug companies that chemists associations [demanded]...a charge of Rs 5,000 to Rs 10,000 to the association of wholesale chemists to stock a new product. Drug companies also gave other incentives to chemists to stock their own products."

Paying physicians to prescribe their medications and pharmacies to stock them has the elegance of a military pincer attack! All that is lacking is getting the patients to ask for the product.

"...Screening camps were used to influence public knowledge about a disease and also expand the market for the drug for that disease."

With direct outreach to the public, all the marketing bases are covered - patients, pharmacies and physicians. Since few medications are paid for by insurance, that sector, which would be important in the U.S., is currently not central in India.

All of the issues described in Mumbai are present in the U.S., but in India the pharmaceutical practices are more brazen. Federal and state regulatory capacity is significantly less in India than in the U.S. Perhaps more important, organizations - medical schools, hospitals, medical societies, and more - currently have less capacity to push back against commercial forces than comparable institutions in the U.S.

But the Indian media is sinking its teeth into the issue of commercial corruption of medical decision making (see, for example, "Are your drugs boosting your doctor's lifestyle?" in yesterday's Times of India here). The same ethical drama is playing out globally, just with different timing.

Drug Trials in India

India is developing drug trials as a budding industrial sector. It is predicted that trials outsourced from the U.S. and Europe will bring $1 billion to India by 2010. But unless institutional review boards and ethics committees get their act together quickly, what may happen instead is a series of political scandals.

Drug trials in India cost 40% - 60% less than in the U.S. or Europe. India offers an enormous, diverse population. Regulation of drug trials are much looser than in the U.S., and expectations about informed consent are not the same.

In 1989, on my first visit to India, I spent a day with a skillful, caring psychiatrist at Banaras Hindu University. He had the patients he saw who could speak English talk with me. After I had spent a half hour (a long time in his fast paced clinic session) talking with a family I asked my host if it would be acceptable to ask the family if I could take their picture. My kindly host, a genuinely compassionate man, said - "Don't ask, just take the picture!"

Earlier this month the World Health Organization Bulletin warned of the potential for an ethical crisis in the outsourcing of drug trials to India. The bulletin quoted Dr Ambujam Nair Kapoor, a senior scientist of the Indian Council of Medical Research, as saying: “Unless we put in place systems that ensure safety of patients and good quality of trials, people will get away with whatever they can get away with.”

It didn't take long for the WHO warning to hit the fan. The Uday Foundation for Congenital Defects and Rare Blood Groups, one of India's huge number of NGOs, obtained information suggesting that 49 infants at the All India Institute of Medical Sciences, a public hospital in Delhi, had died in the course of drug trials.

The report has become a hot political issue. The communist party (not a fringe group in India) has seized on the story as an example of capitalist exploitation of the poor (see here). The ruling Congress party (see here) demanded an independent investigation of the All India Institute of Medical Sciences drug trial situation.

I don't have an independent view of the rights and wrongs of the All India Institute situation. But I can see from the political reaction that public trust of the drug trial industry is fragile at best. India, and drug companies, are incurring a tremendous risk. Regulation in India is limited. The potential for major ethical lapses is large. Lots of money is at stake. Happily, the NGO sector is strong, and will be vigilant in monitoring what happens.

As Maurice Sendak wrote in "Where the Wild Things Are" - "Let the wild rumpus start!"

The Ethics of International Public Health Collaborations

For the past three years I have had the privilege of being able to study the Indian Network for People Living with HIV/AIDS (INP+), an idealistic organization whose threefold mission is to provide networking, direct support services, and advocacy, for people throughout India with HIV/AIDS. My particular focus has been on the partnership between INP+ and the U.S. Centers for Disease Control (CDC) Global AIDS Program in India (GAP-I). My aim has been to learn about how a developed world entity like the CDC can best assist a consumer-driven organization like INP+ based in a very different cultural setting.

A case study of the productive five year relationship between INP+/GAP-I has recently been published in the journal “Organizational Ethics.” In the relatively lengthy case report I drew three potential lessons for developed world funders and donors:

First, like a couple early in a marriage, GAP-I and INP+ have struggled with the question of what they can reasonably expect from each other, how much to pressure each other for change, and how best to apply that pressure. This wasn’t easy. Their experience identified skill at calibrating an optimal level of tension for the partnership as a crucial capacity. Too little tension means expectations are too low. Too much tension leads to severed partnerships. Getting it right requires constant monitoring and frequent recalibration. (The same is true in my clinical specialty – psychiatry.)

Second, the international collaborations between entities like CDC, World Health Organization, Gates Foundation, and Doctors Without Borders, and community-based organizations like INP+, that are so central in the fight against the AIDS pandemic, recurrently bring together partners with different organizational cultures. Successful partnerships require a carefully designed process for bridging the potentially destructive cultural gap. GAP-I located the bridging process in the responsibilities of (a) an Indian man with a strong community background who (b) had a preexisting excellent relationship with INP+ and who (c) was a CDC employee. Whatever mechanism is used, successful collaboration requires robust bridging.

Finally, partnerships between managerially sophisticated, technically advanced developed world organizations like the CDC and community-based organizations like INP+ are especially challenging in the context of different national cultures. Dora Warren, the founding director of GAP-I described the approach she took to the collaboration as follows: “Progress and success is about having trusting relationships. Trusting relationships come partly from informal contact but also from really working together.”

In the course of the study I came to see the GAP-I philosophy of seeking to build a trusting partnership by working together more as a moral perspective than simply as a practical technique. The GAP-I approach is consistent with the concept of “Servant-Leadership” that envisions leading by serving those who are being led. In working with organizations that are strongly mission driven like INP+ the Servant-Leadership method is especially apt.

At a time when the U.S. is widely regarded around the world as trying to "lead" via militaristic bullying, studying the use of the Servant-Leadership approach by a U.S. government agency has been deeply satisfying.