Think Globally Act Locally
Think Globally Act Locally
Vijay Gopichandran
A student of mine attended a medical conference in a five-star hotel and was all excited about it. When you are a medical student who lives in a hostel, these five-star hotel conferences are fascinating. On the morning of the conference, we walk around the rooms in the hostel, borrow the best shirt available in any of the rooms that will fit us, dress up, and go to the hotel. There are usually two main objectives of attending these conferences as a medical student. Excellent free food and an opportunity to take selfies in various ornately decorated places in the hotel and sharing them in the social media pages. Most of these five-star hotel conferences are heavily sponsored by the pharmaceutical companies and patronized by the who’s who in that speciality of medicine in the city. There are a series of lectures and talks on cutting edge medical practice. The conference that my student attended was in one of the poshest hotels in the city. It was a cardiology conference. The same day, after the conference, the student came to meet me in the railway station, where I was returning from the weekly rural clinic.
This student is a particularly smart guy. He knows that I personally do not support or encourage these pharma company sponsored – five start hotel conferences. So, he walked up to me with a pretend long-face and said, “Sir the conference was so boring”. However, his excitement, the happiness and fulfilment on his face and his constant talks about what happened in the conference gave away the fact that he was thoroughly excited about it. I was humouring him and listening to his excited narrative. “Sir, one of the doctors said that having the revised BP cut off 130/80 mmHg to diagnose hypertension is problematic. This is imposing western standards on Indian patients. Why don’t we have our own cut off values?”, asked the student as we walked from the station. “Indian patients are different. Our lifestyle is different, our body composition is different. We eat different food, we live different lives. So, we should have different cut off values for BP. If we follow the American Heart Association’s cut off values, it will be harmful to Indian patients. I think this is a very good question. One of the doctors who attended the conference asked this question. What do you think sir?” he asked.
I was quietly listening to him. I asked him, “You are a very bright student. In your college you score very high marks. So, should I always compare you with the rest of your class, set your class as the gold standard and measure your performance? Or, should I compare you with global standards, help you work harder and achieve a standard that is higher than your class?” “Of course, I should rise to global standards.”, he replied. “The question raised by the professor in the conference is not as simple as it sounds. It would be good to have Indian standards and cut offs for comparison. But that is not always the truth. When I was studying postgraduation, there was a very big debate going on globally about child growth standards. In the late 90’s and early 2000s we were using the United States child growth charts to evaluate whether our children are growing optimally. Applying the US child growth standards showed that a large majority of our children were malnourished. The argument was that we are using the wrong standards. We are comparing Indian children who have different body structure and different environmental exposures with American standards, where the children are inherently bigger than Indian children and they also live in better socio-economic conditions. So, there were people who were advocating for the use of Indian growth charts developed from the study of Indian children. However, there was another group of child growth experts who believed that whether the children are Indian or American, early child growth is uniform and therefore all children must be held up to universal standards. If each country compared their children against their own standards, there would be no chance to make international comparisons. If I score the top marks in my college, that doesn’t say whether I am truly a competent doctor or not. It only says relative to all other students in my college, I performed better. If put in a different class full of high intelligence doctors, I may not even make it to the top ten in the list”, I told him this and kept walking.
The student was a bit annoyed now. I could see the change in his facial expression. He must have attributed my little speech to my disapproval of medical students attending these pharma sponsored five star hotel conferences. This is very typical in our academic cultural context. We seldom separate the person from their views and ideas. If we have an opinion contrary to a person’s viewpoint, the person takes it as opposing him or her and not just their opinion. He asked, “But sir, isn’t it obvious that Indians are very different? What if we use the American standards of blood pressure and land up harming the Indians? Why can’t we have our own cut off values and standards?” “So, do you know for sure that Indian blood pressure is different from American blood pressure? Do we have evidence that if we lower the Indian blood pressure to below 130/80 mmHg then there are serious consequences to this? What is the evidence that we need different standards?”, I asked. I couldn’t say what he was thinking. He was walking quietly. I added, “Setting standards is tough. I should not set standards that are difficult to achieve, unrealistic and harmful. Neither should I set standards that are so low that the major health problem is neglected and brushed under the carpet.”
The conversation was now turning into a lecture. He was silent. I am not even sure if he was listening. I was going on, “If we are able to achieve and maintain a lower target blood pressure of 130/80 mmHg without causing much harm to the patient, then isn’t that better than allowing it to be at 140/90 mmHg? Similarly, if we are able to make our children grow up to American standards, and if we assume that the growth standards there are superior, isn’t it better that our children also achieve such superior growth standards? This is not competition. It is just a way of thinking. Don’t you agree?” He was walking silently, the expression on his face changed to something resembling confusion and disagreement. But he didn’t say anything.
I continued, “Different cut off for American, different cut off for Indians. Ok, let us say we agree with this. What next? Different cut off for the poor and different ones for the rich? Different cut offs for men and different for women? Different cut off for Tamils and different for Punjabis? Where do we draw the line? Now we have a debate on cut off, wouldn’t this debate organically lead to a debate on treatments? Should we also look at different treatments for different people? Should we also debate on rich treatments for the rich and poor treatments for the poor?” This must have created some disturbance in his mind. He stopped looking at me. He started walking, pushing his cycle along, with a bowed head. My aim was not to shut him up. I intended this to be a debate. But often there is such a strong power differential between students and teachers, that having these debates becomes very difficult. In the rich cultural tradition of debates and discourses in India, over the years it has all boiled down to silencing of the weaker voices in front of the more powerful. In this case, though I am not someone who maintains hierarchical structures in my relationship with students, the culture is so deeply ingrained that it is difficult for the students or sometimes me to break it.
I continued the lecture, “The balance between universal standards and relative standards is very fragile. It is not easy to take one side or the other. In situations where there is much to lose when adapting a foreign standard, one should exercise caution. For example, most of the standard guidelines for treatment of diabetes emphasize the use of costlier and more effective oral anti diabetic medicines and the early initiation of insulin treatment. These treatments are often expensive and not possible for the average Indian diabetic patient to buy and use. Therefore, often it becomes necessary for us to use locally available low-cost alternatives. For example, instead of glimepiride, we may have to use glibenclamide, a cheaper alternative. But the goal is to keep the sugar levels in the blood under control and to minimize the long-term complications of the disease. While we may adapt low cost drugs to do the same job, we continue to adhere to strict standards of cut off values of sugars which have been shown to reduce complications and improve the quality of life.”
I went into a brief silent thought and remembered the great demonstration project by the nephrologist Dr. M.K. Mani in rural Kancheepuram where he showed that using low cost medications and adhering to simple community-based treatment and follow up of patients with diabetes and hypertension, a substantial reduction in burden of kidney disease can be achieved. The beauty of the project was that the treatment used low cost and time-tested medications, and the monitoring and follow up was done by community health workers. This is what is referred to as thinking globally but acting locally. The targets and goals are of global standards. Every person in the world should be entitled to the same level of health and quality of life. However, the treatments, monitoring, follow up and protocols must be adapted to suit the local cultural and social context. I broke out from my brief reverie and continued, “While I want Indian children to grow as hale and healthy as the American child, I have to ensure that they achieve this growth through proper feeding of locally available foods. Similarly, I want to achieve very good control of blood pressure among Indians, maybe even 130/80 mmHg if that is possible. But I should use cost effective and acceptable anti-hypertensive medications. To me, setting standards for our care should follow the dictum of ‘think globally but act locally’. If I set standards which are lower than global standards, then I may never achieve global standards of health care to Indians.” I continued, “Having said this, I also think there is a need to set the goals and standards based on current evidence. If indeed an Indian standard is established for blood pressure, my guess is that it will not be much different from the global standards that are currently recommended. When we find reports that most of Indian hypertensive patients are not under fair control of the blood pressure, the response is not to question the goals. The response is to evaluate the reasons for the poor control and intensify efforts to improve it. In all fairness, the benefit that the American experiences out of controlled blood pressure should also be accessible to the Indian.” I had finished speaking and stood there ready to take leave as my home had arrived. The student remarked, “Sir, I never thought of it this way. Maybe you are right. Let me also think about this.” and left. We haven’t spoken about it again after that conversation. I thought it is important for me to document this. I don’t know whether what I am thinking is right. But it appeals a lot to my reason to “think globally but act locally”.
Vijay Gopichandran
A student of mine attended a medical conference in a five-star hotel and was all excited about it. When you are a medical student who lives in a hostel, these five-star hotel conferences are fascinating. On the morning of the conference, we walk around the rooms in the hostel, borrow the best shirt available in any of the rooms that will fit us, dress up, and go to the hotel. There are usually two main objectives of attending these conferences as a medical student. Excellent free food and an opportunity to take selfies in various ornately decorated places in the hotel and sharing them in the social media pages. Most of these five-star hotel conferences are heavily sponsored by the pharmaceutical companies and patronized by the who’s who in that speciality of medicine in the city. There are a series of lectures and talks on cutting edge medical practice. The conference that my student attended was in one of the poshest hotels in the city. It was a cardiology conference. The same day, after the conference, the student came to meet me in the railway station, where I was returning from the weekly rural clinic.
This student is a particularly smart guy. He knows that I personally do not support or encourage these pharma company sponsored – five start hotel conferences. So, he walked up to me with a pretend long-face and said, “Sir the conference was so boring”. However, his excitement, the happiness and fulfilment on his face and his constant talks about what happened in the conference gave away the fact that he was thoroughly excited about it. I was humouring him and listening to his excited narrative. “Sir, one of the doctors said that having the revised BP cut off 130/80 mmHg to diagnose hypertension is problematic. This is imposing western standards on Indian patients. Why don’t we have our own cut off values?”, asked the student as we walked from the station. “Indian patients are different. Our lifestyle is different, our body composition is different. We eat different food, we live different lives. So, we should have different cut off values for BP. If we follow the American Heart Association’s cut off values, it will be harmful to Indian patients. I think this is a very good question. One of the doctors who attended the conference asked this question. What do you think sir?” he asked.
I was quietly listening to him. I asked him, “You are a very bright student. In your college you score very high marks. So, should I always compare you with the rest of your class, set your class as the gold standard and measure your performance? Or, should I compare you with global standards, help you work harder and achieve a standard that is higher than your class?” “Of course, I should rise to global standards.”, he replied. “The question raised by the professor in the conference is not as simple as it sounds. It would be good to have Indian standards and cut offs for comparison. But that is not always the truth. When I was studying postgraduation, there was a very big debate going on globally about child growth standards. In the late 90’s and early 2000s we were using the United States child growth charts to evaluate whether our children are growing optimally. Applying the US child growth standards showed that a large majority of our children were malnourished. The argument was that we are using the wrong standards. We are comparing Indian children who have different body structure and different environmental exposures with American standards, where the children are inherently bigger than Indian children and they also live in better socio-economic conditions. So, there were people who were advocating for the use of Indian growth charts developed from the study of Indian children. However, there was another group of child growth experts who believed that whether the children are Indian or American, early child growth is uniform and therefore all children must be held up to universal standards. If each country compared their children against their own standards, there would be no chance to make international comparisons. If I score the top marks in my college, that doesn’t say whether I am truly a competent doctor or not. It only says relative to all other students in my college, I performed better. If put in a different class full of high intelligence doctors, I may not even make it to the top ten in the list”, I told him this and kept walking.
The student was a bit annoyed now. I could see the change in his facial expression. He must have attributed my little speech to my disapproval of medical students attending these pharma sponsored five star hotel conferences. This is very typical in our academic cultural context. We seldom separate the person from their views and ideas. If we have an opinion contrary to a person’s viewpoint, the person takes it as opposing him or her and not just their opinion. He asked, “But sir, isn’t it obvious that Indians are very different? What if we use the American standards of blood pressure and land up harming the Indians? Why can’t we have our own cut off values and standards?” “So, do you know for sure that Indian blood pressure is different from American blood pressure? Do we have evidence that if we lower the Indian blood pressure to below 130/80 mmHg then there are serious consequences to this? What is the evidence that we need different standards?”, I asked. I couldn’t say what he was thinking. He was walking quietly. I added, “Setting standards is tough. I should not set standards that are difficult to achieve, unrealistic and harmful. Neither should I set standards that are so low that the major health problem is neglected and brushed under the carpet.”
The conversation was now turning into a lecture. He was silent. I am not even sure if he was listening. I was going on, “If we are able to achieve and maintain a lower target blood pressure of 130/80 mmHg without causing much harm to the patient, then isn’t that better than allowing it to be at 140/90 mmHg? Similarly, if we are able to make our children grow up to American standards, and if we assume that the growth standards there are superior, isn’t it better that our children also achieve such superior growth standards? This is not competition. It is just a way of thinking. Don’t you agree?” He was walking silently, the expression on his face changed to something resembling confusion and disagreement. But he didn’t say anything.
I continued, “Different cut off for American, different cut off for Indians. Ok, let us say we agree with this. What next? Different cut off for the poor and different ones for the rich? Different cut offs for men and different for women? Different cut off for Tamils and different for Punjabis? Where do we draw the line? Now we have a debate on cut off, wouldn’t this debate organically lead to a debate on treatments? Should we also look at different treatments for different people? Should we also debate on rich treatments for the rich and poor treatments for the poor?” This must have created some disturbance in his mind. He stopped looking at me. He started walking, pushing his cycle along, with a bowed head. My aim was not to shut him up. I intended this to be a debate. But often there is such a strong power differential between students and teachers, that having these debates becomes very difficult. In the rich cultural tradition of debates and discourses in India, over the years it has all boiled down to silencing of the weaker voices in front of the more powerful. In this case, though I am not someone who maintains hierarchical structures in my relationship with students, the culture is so deeply ingrained that it is difficult for the students or sometimes me to break it.
I continued the lecture, “The balance between universal standards and relative standards is very fragile. It is not easy to take one side or the other. In situations where there is much to lose when adapting a foreign standard, one should exercise caution. For example, most of the standard guidelines for treatment of diabetes emphasize the use of costlier and more effective oral anti diabetic medicines and the early initiation of insulin treatment. These treatments are often expensive and not possible for the average Indian diabetic patient to buy and use. Therefore, often it becomes necessary for us to use locally available low-cost alternatives. For example, instead of glimepiride, we may have to use glibenclamide, a cheaper alternative. But the goal is to keep the sugar levels in the blood under control and to minimize the long-term complications of the disease. While we may adapt low cost drugs to do the same job, we continue to adhere to strict standards of cut off values of sugars which have been shown to reduce complications and improve the quality of life.”
I went into a brief silent thought and remembered the great demonstration project by the nephrologist Dr. M.K. Mani in rural Kancheepuram where he showed that using low cost medications and adhering to simple community-based treatment and follow up of patients with diabetes and hypertension, a substantial reduction in burden of kidney disease can be achieved. The beauty of the project was that the treatment used low cost and time-tested medications, and the monitoring and follow up was done by community health workers. This is what is referred to as thinking globally but acting locally. The targets and goals are of global standards. Every person in the world should be entitled to the same level of health and quality of life. However, the treatments, monitoring, follow up and protocols must be adapted to suit the local cultural and social context. I broke out from my brief reverie and continued, “While I want Indian children to grow as hale and healthy as the American child, I have to ensure that they achieve this growth through proper feeding of locally available foods. Similarly, I want to achieve very good control of blood pressure among Indians, maybe even 130/80 mmHg if that is possible. But I should use cost effective and acceptable anti-hypertensive medications. To me, setting standards for our care should follow the dictum of ‘think globally but act locally’. If I set standards which are lower than global standards, then I may never achieve global standards of health care to Indians.” I continued, “Having said this, I also think there is a need to set the goals and standards based on current evidence. If indeed an Indian standard is established for blood pressure, my guess is that it will not be much different from the global standards that are currently recommended. When we find reports that most of Indian hypertensive patients are not under fair control of the blood pressure, the response is not to question the goals. The response is to evaluate the reasons for the poor control and intensify efforts to improve it. In all fairness, the benefit that the American experiences out of controlled blood pressure should also be accessible to the Indian.” I had finished speaking and stood there ready to take leave as my home had arrived. The student remarked, “Sir, I never thought of it this way. Maybe you are right. Let me also think about this.” and left. We haven’t spoken about it again after that conversation. I thought it is important for me to document this. I don’t know whether what I am thinking is right. But it appeals a lot to my reason to “think globally but act locally”.
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