But let us not forget that “hope” is the source of our greatest strength. I hope that in 2017, bumps in the road like Trump will not weigh down upon our energies for action. I hope that young people will not be pessimistic. The most important thing for young people to do is to act – get each of our acts together, and help the rest of the world get their acts together too. I hope that young health researchers will lead the way towards planetary health, and show how it can be done collectively. The evidence is there! The platforms are there (the SDGs, the Paris Agreement)! The strategies are there! The ethical basis for action is also there!

For the poor in India, 2016 brought with it several usual and unusual – enter “demonitisation” – challenges. What I hope to do in 2017 is this: to engage (with my team) and local people in addressing issues of hunger and water in 100 villages, and encourage 50 young health students and professionals to become planetary health champions.

Can’t wait.

Melinda and Bill Gates are keen on bringing time (and gender equity) and energy (and dignified livelihoods) to the masses – Melinda specifically focuses on women in the Global South. Both are, clearly, good thoughts.

From my point of view, some of the issues worth reflecting about in this context are these:

1. Mr and Mrs Gates usually support “politically correct” issues, such as education, agriculture (technology) and healthcare (technology). True, not everybody agrees they are all politically correct issues, but you know what I mean. Meanwhile, in many countries (and India is surely one of them, currently) NGOs are not allowed by governments to engage with direct “politics” – that is, towards mobilising and empowering communities based on issues. Yet, one could argue that with improved availability of time and energy, people will have the opportunity (and the “energy”!) to engage with the politics of power, thereby attempting to address the underlying determinants of ill health and marginalisation. This could be an interesting and, dare I say, transformative spin-off of Bill & Melinda’s idea! (not sure they’ve thought it fully through)
2. Because of their tendency not to get involved in “political” work (at least not openly), their focus is more on service provision and facilitation, hence the (over)emphasis on technology. There is no denying the importance of technology in improving wellbeing, but two issues become of concern here: technological optimism in the face of disaster, and risky (and potentially catastrophic) technology. Evidence of the former is Bill Gates’ hope for an energy “miracle” (granted, he tries to boost the likelihood of this miracle happening, financially and via other means, so it’s not just pie-in-the-sky). We too hope for a technological breakthrough, but meanwhile we should not wait with our hands folded on a number of other aspects that seem key in the battle against climate change. The latter is an aspect not much touched upon in this annual letter but has previously been mentioned by Mr Gates – involving issues such as geo-engineering and genetically modified crops. A bit less politically correct, clearly. But Bill Gates does also emphasise harnessing solar and wind to the extent possible.
3. Women still get disproportionately overworked and underpaid, and surely there is a lot of scope to address this in developing countries – again with India as a case in point, as Melinda Gates rightly stresses. The two seemingly simple interventions of household water supply and cooking fuel could really help with “time” (besides huge health benefits), and should receive greater attention. But it is also worth remembering that waiting for an energy miracle without addressing carbon emissions in the meantime will only worsen the situation of both water and fuel for the most marginalised societies (through multiple mechanisms), and so there is more than enough reason to phase out fossil fuels (and replace with renewable energy to the extent possible) as soon as possible, irrespective of the energy “miracle” (that hopefully will materialize sooner rather than later).

To conclude: if anything, what we can indeed learn from Melinda and Bill Gates is how they use their time and energy to work hard towards the world they dream of, a fairer world where all lives have equal value. By the way, I have no doubt that they work harder than I do, whether previously at Microsoft or currently at their Foundation, and so this is a message I take away from their letter.

I may not have the bucks, but I do have the time and energy, and that should be enough to make my own contribution to a fairer and sustainable world!

My carbon footprint excluding my out-of-city travel is 2 T/year, which is approximately the recommended average per capita emission for preventing further climate change. With my current travel (work and personal) included it becomes 5 T/year, which will soon come down to 2 T/year when my wife completes her education and we return to our hometown. If I register for a PhD abroad, my footprint will continue to be in the order of 5 T/year for the next 3-4 years. On the other hand, by registering at a local university it could come down to 2 T/year immediately, though potentially compromising the kind of technical input I may get. By the way, my carbon footprint is this low because of a combination of factors – low electricity use (including manual washing of dishes and clothes – a relaxing time and a good workout respectively), exclusive use of public and active transport to office (which includes 25 minutes on the local bus and 25 minutes of walking, each way), eating vegan (only plant based food), and reducing waste (including recycling grey water). I have also consciously cut down air travel (with the aim of phasing it out completely over time).

Five sets of questions occur in my mind:

• Is it okay to justify a bit more pollution now (to study abroad) by engaging with work aiming at population-level pollution reductions in the future, and thus (probably) be more effective in the future?
• Can I claim to work on addressing environmental health when my current personal carbon footprint is more than what is sustainable?
• Can I gain the skills I need for better engagement with these issues at a local university (where they do not have domain expertise in environmental health)? Can I make the difference I am hoping for without drawing upon (what appears to be) the best educational opportunity available to me?
• Is it likely that my temporary engagement at a developed country (through a university) could further encourage local action towards sustainability there? For instance, I was the sustainability officer at LSHTM when I did my MPH. Did that make any difference?
• Is it time now for each country (and all universities) to look inwards – to change practices within their own countries to sustainable levels?

I am weighed down by these thoughts and there are no clear answers. But these are important questions, and ones that each health researcher (not just the environmental health researchers) should reflect upon in the new SDG era, especially the new generation – chances are the old ones won’t want to change their ways anymore, even if they should as well. It is fairly easy to rationalise any decision, or find “mitigating circumstances” (family related ones, professional excuses, …) for a higher carbon footprint, and so there is a need for a deeper engagement with them.

While some may be prone to being cynical and ponder whether individual steps will make any difference, I think there surely is a role for us – both from an ethical perspective and a public health practice perspective. I think young health leaders can show the way towards a sustainable and better future. I urge you to start checking and monitoring your carbon footprints!

For the purpose of this blog, we define the “haves’ here in line with a recent paper by Edward & Sumner, comprising both the “prosperiat” (the global top 10 percent — or 700 million people with a consumption of $30 or more per day; the prosperiat includes the so called  1 % and 0.01%, but clearly goes beyond this category of super-rich) and the “securiat” (people who live on $10-30 a day; i.e. the 1.5 billion people who are secure from falling back into absolute poverty but not (yet) prosperous). As for the “have-nots”, they are made up of the “global destitute” (less than $2 – estimated at one billion people) and the “global absolute poor” (less than $4 – estimated at 2.5 billion people); to a lesser extent, “the precariat” ($4-10 a day – insecure 2 billion people) can also be considered part of the have-nots, as access to basic services is not guaranteed for them.

Until now, governments, NGOs and philanthropists have been mainly talking or working towards addressing the basic needs of the have-nots, while the rich – i.e. the “haves” – were largely unhindered in their quest for acquiring more, and more, and more. Grassroots organisations have become experts in building communities amongst the poor, and in engaging with these groups towards their development. Conversely, and unfortunately, there has not been much work towards engaging with the rich, especially in the context of changing their behavior and reducing their excesses (which many of them/us still feel not necessary to reduce, by the way, as we don’t consider our behavior as ‘excessive’). Yet, at exceptional times in history, including during the world wars, everything was rationed so that everyone got enough of what was needed (as described by Naomi Klein in This Changes Everything), or at least portions were more or less divided evenly. In the new SDG era, we’re nowhere near yet, even if more and more rich begin to have a vague notion that we can’t continue this way.

How have “the rich” been engaged in developmental discussions until now? The ultra-rich have been drivers of economic policy (for better or for worse, see their activities in the financial sector, including in tax havens), providers of employment; the more progressive ones among them are also active as philanthropists. The rest of the rich (i.e. the bulk) have mostly been consumers, employees, and are driving through their sheer mass also the (direction of the) world economy. Several campaign groups have sought the support of some of the Super-Rich (with Bill Gates as the most prominent example) towards specific social justice issues and to fund campaigns. The rest of the rich have largely been supportive of the status quo (read liberalization and privatization) on developmental policies, and are by and large adhering to capitalism (whether the Anglo-saxon or softer European version, or “made in China” state capitalism), even if sometimes reluctantly. Occasionally they voice opinions on social issues such as corruption and gender equality.

But if we really want “to leave no one behind” in the SDG era, it is time to zoom in (more) on the behavior of the rich, broadly defined as we do here. While governments have a key role in terms of ensuring that appropriate policies are in place to reduce excess consumption and consumerism among the rich, the success of the implementation will also depend on a shift in the mindset of the rich.

There is a need for a change in the vision that the super-rich are “the lords of the land” or “saviours of the poor”; instead, they’re often perpetrators of inequity and worldwide pollution. In the new SDG era, they will now have to become “partners” – a word they’re very fond of – along with everyone else towards building a better, just, and sustainable world.

As for the rest of the rich, the vast majority, they’ll need to thoroughly examine for themselves what ‘sustainable consumption and production patterns’ actually entail. Which means they (and this includes most of the people reading this very blog, including the writers of this piece) need to redefine the American dream, the Chinese dream, the Indian dream, the global health researcher dream… you get the idea. This is not about “sacrificing” luxury, but rather about truly engaging with a process that can ensure an even better world with a comfortable and dignified life for everyone, including them/ourselves. It’s about giving up a false notion of “power” and ‘moving ahead in life’, rather than about giving up power and progress itself.

Of course, among the super-rich, power and wealth have often been used to acquire even more power and wealth, and so this kind of power surely should be given up – after which they will have an opportunity to embrace and savour the power of collective action for the collective good. (as you can tell, we’re already being “inspired” by Jeremy Corbyn’s recent victory in the Labour elections in the UKJ)

There is also a role for civil society and governments in this effort, and of course, any leaders that might emerge from within the richer sections of society. Maybe also religious institutions will play an important role towards guiding the rich (within their communities) towards these – very much needed – changes. Moderation in consumption as an idea is compatible with (and indeed recommended by) all religions and many philosophies, based on what we have understood of them. And such shifts make possible more active, engaged and fulfilling lives. The same is true for atheists from an ethical perspective. In spite of all the fancy talk of ‘green growth’, some level of moderation and balance (implying also an absolute reduction in consumption) will be necessary for the haves – no doubt about that. But moderation does not necessarily mean a reduction in opportunities and services. For instance, moving around the city as much as before will still be possible, but on cycles or using public transport; wearing fancy clothes everyday will still be possible, but clothes will be bought less regularly (and not as easily thrown away);  children would more often get to play football outdoors rather than always being ‘immersed’ in gaming devices inside homes; and fruit can (and should) still be eaten every day, but it would more often be grown locally rather than imported from across the world. Well, just some crude examples.

Maybe the public health community can engage through the knowledge that has been gained through health promotion. Some institutions of the public health community are already divesting from coal and fossil fuel companies. Ethics (and long term benefits) have to come before short-term profits, and have to be guiding principles towards the success of the SDG era.

In short, the development sector will have to move out of its comfort zone and broaden its vision to include the “neglected rich” if it wants the sustainable development agenda to be successful. A focus on the neglected rich has not been proposed here with the idea of creating even more silos; we just want to argue here that now is the time for innovation towards engaging with this socio-economic group – which until now was not of much “concern”.

We know especially the super-rich like to think of themselves as being innovative, generous and thus contributing to the SDG agenda – via philanthropic foundations, social impact bonds and the like, the Giving Pledge, …  Without any doubt, it’s true that at least some of them don’t “neglect” the SDG agenda. Yet, their own behavior is still to a large extent neglected, and the world, including the development community, needs urgent innovation to address that oversight. The same goes for the rest of the rich – hundreds of millions of people.

Then, perhaps, if we dare to dream, we will one day wake up in a world where we no longer talk of “haves’ and “have nots”… and human beings all over the world just live dignified and comfortable lives.

Environmentalists watched as if in a trance,

The negotiations that happened in Paris, France.

But it was the same old show,

As they all want to “grow”,

And so there was no change in stance.

This limerick portrays a situation which some of us don’t want to witness in a few months’ time. As we embark on another World Environment Day celebration on 5^th June, the year holds both hope and cynicism about the future of both global environment and health. The Sustainable Development Goals (SDGs) and the climate change treaty will soon be upon us (2015), or so we hope at least – two exercises that have been and will be very resource intensive in their own way, but are nonetheless some of the acceptable ways we know of moving collectively towards solving matters of global significance. Sometimes these diplomatic ventures serve as a guiding light, but often they become excuses for real action. In a globalised world, it is unlikely that any country would take up altruistic measures to mitigate carbon emissions in the short term without a global agreement.

“Healthy People, Healthy Environment” was the theme of the 14^th World Congress on Public Health (WCPH), held earlier this year in February in Kolkata, India. When I first read about this theme over a year ago, I felt that maybe it should have read as “Healthy Environment, Healthy People”. There is no way we can have healthy people without a healthy environment; it is a prerequisite to health.  While the organisers themselves could have taken better care to appropriately manage waste, tackle mosquitoes and use and disposal of bottled water at the conference, it was great to have a platform to discuss issues on environmental health. The conference also had an unusual, and very interesting parallel session on planetary health, which differs from global health in its focus on ecology, sustainability and human health. At the WCPH, a few round table sessions were also organised on the theme of “Energy and Health”, where I served as a resource person.

As efforts are underway in India to rouse the health sector (especially the academic public health sector), there is an opportunity to integrate environmental health in a larger way. Generating sufficient energy is necessary for economic growth and also the health and well-being of people, but the approach to production, distribution and utilisation needs reflection. These are touchy times to be discussing energy generation and consumption in India. Lessons learnt from the past (industrialized nations) reiterate the need to achieve a balance between energy for economic growth and industrialization, and the need for energy which is sustainable, responsible and generated in a way in which it does not negatively impact people and the environment directly or indirectly. Yet, starting a conversation with those in power (pun intended) is a challenge. For all the discourse on equity, wellbeing, social determinants, human development, conservation, intergenerational equity and precautionary principle, the idea guiding decision-making on developmental issues still boils down to GDP. It is even more unfortunate that those with greater historical responsibility globally, have largely shied away from addressing the need for systemic change. It is quite easy to understand why developing countries are not taking the need to mitigate environmental damage seriously in the absence of the willingness of industrialized nations really showing they mean business. The ‘He Says, She Says’ and ‘You First’ attitudes, are tragic in a world that is not devoid of wisdom. Mixed feelings also emerge from the ongoing negotiations in Bonn about what might result from the Paris Conference of Parties (CoP).  INDCs are all the rage now in climate talks, but the aggregated “sum of all INDCs” will probably not keep us within a 2 degrees rise, as things stand a few months before the Paris summit, which is why French officials are already saying we also have to think of a good process to review things and adjust, if necessary, in the years after Paris. That’s like saying to a high school student, well, “you didn’t pass this time, but hey, we’ll think of a nice mechanism to keep reviewing your score in the months to come, and then hopefully, some day, you’ll pass”. Go figure.

On a more serious note, there is, I believe, a need for more voices from the health sector to be heard at such conferences, in India and globally. A health sector response to the issues of energy, energy policy and climate change is necessary, and there is no better time for this. This sentiment was also recently echoed at the 68th World Health Assembly. Health professionals from all countries would do well to engage this year in shaping our collective future. The London School of Hygiene & Tropical Medicine has just divested from coal. Hopefully others will follow, and these messages are heard. Many members of the Emerging Voices community, including myself, are also passionately engaged with the health and environment community to discuss these issues. It’s now or never; this is the time for action, or we should forever hold our peace (pieces rather).

The NGO movement in India began a few decades ago driven by both a passion for serving the poor and a disenchantment with the ability of the government to provide basic needs for the entire population. Several developmental and health non-governmental organisations (NGOs) were set up, largely in remote rural areas. With time, the number of NGOs grew, and also the agenda diversified. Various new streams of thoughts emerged, including ones on human rights, community building, and environmental protection, with a realisation that it is not the place of NGOs to address all the gaps in service, but to strengthen participation and systems. Needless to say, the work of all these kinds of NGOs is related to health.

NGOs have provided services to the needy, and have raised the voice against oppressive practices. They have demystified information about the rights of people. NGOs have also questioned decisions made at various levels which may affect the most marginalised communities, or the long term well being of the population. They critiqued decisions made in the name of development, but have not been opposed to humane and ecologically sustainable development. Most notably, and historically, it was the Bhopal Gas Tragedy that saw and continues to see several confrontations between the government and civil society. Suspicion about the NGO sector and its perception as a threat has only grown ever since. This feeling was associated with, but was not limited to, a number of health NGOs. Of course, some kinds of health NGOs do not face this problem. For instance, opening up a mission hospital is not seen as a problem, but asking about healthy clean energy is. And so on. Despite this fact, the value of NGOs and the experience of individuals within the NGO sector in the field of development have occasionally been acknowledged and harnessed by some preceding governments in drafting policies and strategies.

I (or most people for that matter) do not to say that NGOs are always right. There are many that are corrupt, many that are incompetent, and some that are even actively working towards the interests of corporate or other powers (at the cost of the vulnerable). But there are many which are seriously concerned with social justice, equity and development. And these NGOs raise valid concerns, and these concerns should be considered transparently in decision-making. Responses to these concerns should be given, and the logic of the decisions made should be discussed. It is a fact that a large part of India’s population has been at the receiving end of piecemeal tokenistic nibbles by government after government for way too long. And during this time, power has systematically been accumulated by a few. Big business has been claimed to be the feeder of the masses and the reliever of oppression. And so those who have questioned this logic are being seen as threats to development itself.

At this uncertain time for NGOs, it is important for solidarity across various institutions. Some of these concerns are not limited to India alone. There is also a need for reflection. Checks and balances are necessary in a democracy, and NGOs contribute to it. It is worth engaging in the debate on democratic spaces in India, for the sake of public health.

The first one was that those portrayed as “the bad guys” in movies like these always seem to have a better grasp of the need for urgent action to prevent global environmental change, and have some kind of (distorted) compassion for the larger world or at least for the survival of future generations.  [Spoiler alert!] In Kingsman, for example, a maverick billionaire portrayed terrifically by Samuel L Jackson is quite keen on triggering mass hysteria and killing using some kind of electromagnetic wave, all with the aim of drastic population reduction and prevention of climate change. While the knights in shining armour, the secret service agents working for an independent institute (called Kingsman), eliminate this threat very professionally using the usual spy-type competencies and skills, they do not follow it up with necessary action to prevent/mitigate global environmental disaster. Things, I assume, go back to business as usual. There is no acknowledgement in the movie that the situation is indeed demanding drastic measures, which politicians are unwilling to take. What’s more, the young daredevil spy is immediately rewarded by a sexy diplomat after his intervention foiled the bad guy’s plan! (Good for him, I guess)

As can be seen, the “heroes” in these blockbusters are typically more concerned about human rights and immediate welfare ( their definition of ‘saving the world’) but don’t necessarily have a long term vision for survival and prevention of global disasters. In a way, they are similar, at least to some extent, to some of the ‘real world’ philanthropic billionaires who are pumping funds into developmental and human welfare activities, but are not necessarily challenging current systems (with an understatement) to prevent future ecological mayhem. So they are different from the kind of bad guy billionaire played by SL Jackson on screen. The ‘real world’ ones are currently concerned about immediate human welfare, whereas the billionaire on the screen was more concerned about long term survival of the human species (we know philantrocapitalists nowadays just love to use the word ‘resilience’ to show their long term vision, but they don’t seem to think through the implications in terms of how the economic system should be organized to make it really resilient and respecting planetary boundaries). Common sense dictates we should be concerned about both of them.

This brings me to my second feeling. Some of the movies listed above show post-apocalyptic scenarios where humans have successfully destroyed global ecological systems through technology and consumption, and are now looking for escape plans and solutions for survival. So, these guys who make the fancy escape plans after things go terribly wrong because of callous disregard for issues that need our urgent attention…these are our heroes?

We all know Hollywood blockbusters can be ridiculously simplistic, but still.

Plans such as the one plotted by SL Jackson’s character are obviously not an option (I felt I had to clarify my stand here!). But we do need ideas, people! How are we going to do something meaningful, and urgently? I am getting rather pessimistic as we move along. Our political, economic and cultural systems do not allow for meaningful action, and we will be left in a sorry state (not unlike the polluted Yamuna river, a tributary river of the Ganges, you see in the accompanying picture, a picture taken in Delhi, which I visited in 2011).

The SDGs, for instance, have been critiqued by some as a basic minimum consensus arrangement, not ambitious enough to really challenge/change current systems, and without a clearly spelt out driving vision for a future world. Also, it does not help when those seeming to work on environmental issues regularly post pictures of exotic  meat they’re eating  (that might be a bit of a pet peeve of mine, being a vegetarian, yet, there is some truth in it, if one takes into account the huge contribution to climate change by meat consumption) . Motivation is fragile, and cynicism is unfortunately the order of the day, and so those hoping to make an impact shouldn’t be pushing the envelope any further.

It appears that humans will have to eventually build rocket ships to fly away from a dying Earth, and will carry the burden of genocide of the largest order in the form of mass extinction of species and ecosystems – a legacy of billions of years wiped out in a few years; all for luxury, material comfort, and, ironically, ‘longevity’. Or will, against all odds, some heroes rise among us to break the shackles of complacency in our current systems and save the day? Because if we decide to sit by and wait, some “bad guy” in the real world may get motivated enough to undertake drastic tragic action.

Geo-engineering, for example.

Acknowledgements to Kristof Decoster for his inputs.

“If they can’t have meat, they must want a substitute; let them have fake meat!”, an effort to alleviate the poverty of the palate!

Did I echo the thoughts of the cooks here? Probably not. That was just a thought of an excited mind. A mind of a hungry vegetarian trainee in the midst of a hectic training program held at Cape Town, far away from his country and from what he recognises as good food. But let us not forget that in many parts of the world, the absence of meat on the table does indicate poverty, where meat is only consumed at important events and celebrations due to affordability.

Coming back to fake meat, it was also possible that the cooks assumed that vegetarians enjoy fake meat preparations. It is made of soy with texture similar to meat. For those who have been vegetarian from childhood, such presentation and texture would generally be revolting. However, it is likely that those who’ve given up meat as adults would find it more acceptable.

It is also entirely possible that the cooks in Cape Town genuinely lacked knowledge of proper vegetarian cooking. To understand this further, let’s go back to the day I arrived in Cape Town, a week before the fake meat fiasco. It was dinner time and I looked into the menu at the hotel where I was put up. Few vegetarian options, and none looked very appetising. There was the omnipresent cheese and tomato sandwich, but that would be the last resort. I decided to walk down to a nearby store to check my options there. Cheese and tomato sandwich it is! And incidentally, I don’t eat dairy either when I am in more controlled environments.

Each night that followed, at dinner we were served dishes composed primarily of cheese or cream with a hint of vegetables or pasta in them, which became very difficult to eat regularly. This is besides the surprising poor quality of pasta and risotto served on some occasions. Often I would go back to my room, not having eaten, to find relief in sweets and junk food. But I do thank the organisers of the EV program for trying to arrange for vegetarian options at each meal, to the extent that was possible from their end. This is in stark contrast to the experience we had at the HSG conference, where I didn’t have lunch for three days straight either due to lack of food or of edible options.

Anyway, the content and quality of food were only part of the food experience. There were also human interactions which compelled me to reflect. As can be imagined, the group at the program had a minority of vegetarians (approximately 6 out of 70 individuals) and we had a small table serving vegetarian food during the lunches with few options. Some non-vegetarians would help themselves first at the relatively lavish spread prepared for them, and then hop towards the vegetarian spread to see if they could top up their plate with a few more goodies. There were a couple of times where vegetarians who came late to lunch did not get much to eat because the food was finished. It hurt me to see that, as I could imagine their plight. However, it was nice to see some of the vegetarian trainees handle these awkward situations of unconscious conflict quite well, by going over to the perceived offender and informing them about it in a gentle way. This is something I have generally been bad at.

At one lunch, I observed with rather unreasonable shock when a co-trainee dipped his beef appetizer into the chutney placed on the “Reserved for Vegetarians” table. Reflecting back on that incident now, I feel the shocked reaction may be less to do with his action, and more to do with the fact that I wouldn’t be using that dip that afternoon. I say “unreasonable” because the concept of vegetarianism does not exist in many parts of the world and probably from where he belonged to as well.

Some of you may know that there is a cultural basis for vegetarianism in India. Those belonging to the Jain religion and also a fraction of the Hindu community are vegetarian by tradition. And hence these communities have rich cuisines developed over centuries, which is the stuff I eat regularly back at home. I was born into a vegetarian household, but I turned vegan a few years ago due to ethical reasons (not related to my community’s traditions). Vegetarianism is now but a ritual for most vegetarians in India who are oblivious to the basis of their traditions (related to “impurity” and “sin” associated with eating meat). It is also not surprising that many do not follow this practice any longer as they don’t associate with that kind of thinking. None the less, being a vegetarian is a political statement (as intended by some), though in India we have the unfortunate association of vegetarianism with social elitism (the social elite Hindu “caste” in India follows vegetarian practice) conveying a different kind of political message to some, which is not the intention in my case at all.

Now I am back at home, sipping on some excellent soup prepared by my wife, and putting down these thoughts in words. In any case, before I travel to strange foreign lands next time, I will stock up on some emergency supplies to make feast and avoid fake meat!

Acknowledgements to Angeli Rawat (EV 2014 and co-suffering vegetarian) and Lahari Joshi (wife)

Here I pause to provide context to the situation of young doctors in India, something the speaker was unable to do at the panel discussion mostly due to time constraints. A basic medical training is considered inadequate both by doctors and by the society in general (for various reasons), and so there is a great pressure on young medical graduates to enter a postgraduate training program. The process towards entry into a postgraduate training program in India may most accurately be described as a rat race. Some wise person has stated that in a rat race, even if you win you are still a rat. The reason it becomes a rat race is that the chunk of cheese is small and there are too many rats. There are relatively very few postgraduate training opportunities as compared to the number of young medical graduates. So much so that while preparing for these entrance tests (which can take on an average two years, while doing nothing else), most of my classmates lost enough weight to start resembling rats. I conveniently decided to exit the system early on by taking up a research career.

We have a situation where young doctors are desperate. So desperate that they would go to these to remote hilly areas to get an edge in the exams. This has led to another rat race for positions in those remote healthcare facilities. Therefore the life of a young medical graduate is basically a series of rat races, making “rat-triathlon” a more appropriate coinage. Due to this, it becomes a bit difficult for me to accept such incentives as innovations, though I completely agree about the need for doctors to work in those areas and other such areas of need. I guess most of the young doctors have very good experiences too from these remote areas effectively making them both good clinicians and also potentially community oriented.

Coming to the other side of the catch-22 situation, the health system also has another important priority, which is to increase the number of opportunities in postgraduate medical education. Now if these opportunities are increased, will it mean that the quota system progressively becomes an ineffective tool? As we can see, the two priorities here – postings in rural areas, and increasing postgraduate educational opportunities are in conflict with each other (by virtue of educational opportunities being used as incentive for postings to hilly regions). In such a situation, how else might we bring doctors to those areas? Maybe I’m just over-thinking it, and there will always be young doctors dependent on such systems for accessing better opportunities, educational or otherwise. Or there will be other incentives, which will appear with changing times, needs and situations.

These were just random musings that occurred to me while listening to the delegates the other day.