doctor marketplace & lack of system improvement (delhi summer illness 4)

One of the first things you learn when studying health systems is how imperfect health care markets are — limited time or ability to shop around, massive information asymmetries, etc. It is interesting, then, how very marketplace-like was my experience during my most recent illness episode. It is even more interesting, i think, that this took place within the same corporate hospital system — calling into question the very benefits of such an aggregated system.

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To briefly recap,  i had (still have, actually) symptoms consistent with chikungunya,  [~chicken-goon-yuh] which is currently breaking out in Delhi but which was not actually confirmed in my case. i managed to visit three doctors in as many days to try to figure out what was going on, which is probably the most ‘shop-around’ approach i have ever taken to a single illness episode. [The desperately curious can read the previous posts on observations from navigating the hospital and health system while being sick: here, here & here.]

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First, i saw my regular GP. Then, with some urging, i saw a recommended GP. In the interim, i had also scheduled an appointment with a rheumatologist given (a) relevant family history and (b) that my only early symptoms were joint pain , weakness & fatigue — no fever nor rash. In this post, i just focus on the GP visits.

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The visit to my regular GP on Tuesday led to my being tested (IgM) for chikungunya as well as dengue and malaria (as precautions than really being indicated). i learned on Wednesday morning that the IgM was negative but as my white blood cells were high, i was put on an antibiotic (for a ‘post-viral infection’) and given the obligatory paired antacid + anti-inflammatory as well as calcium for unexplained reasons. i actually don’t think an antibiotic was indicated and was a bit annoyed when i asked if anything else could be causing the joint pain and was told no, which is of course a silly statement since plenty of things cause joint pain, not all of them infectious.

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In the interim, through the healthcare recommendation grapevine that is Delhi, i learned about another doctor who was recommending a different chikungunya test (and promoting himself as a chikungunya guru). With some urging, i followed-up there was well on Wednesday afternoon, for a (super) special clinic double-feature day.

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The second GP i saw was in the same corporate hospital system but at a different branch, less than 5 km away. i came in with high hopes for the recommended doctor, most of which were dashed over the course of the short visit. i should note that for this visit, my (male) colleague kindly accompanied and the (male) doctor spent much of the limited attention he gave to either or us (rather than his computer screen or his phone) addressed to my boss. i have never felt so blatantly part of a capitated (pay-by-patient or ‘per head’) system as i did over the course of this week of doctor visits. (A particularly endearing moment came when i asked the doctor to explain my morning’s lab report and why the white blood cells might be elevated — and i was told to google the answer.)

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The doctor spot-diagnosed me with chikungunya while i was still shuffling in the door, before i was able to sit down and say anything beyond ‘joint pain.’ Perhaps some patients are impressed by this sort of act. i was not. The doctor did very little looking at me and certainly never touched me. i had to really push to get out a description of the specific type of joint pain i was experiencing. Much of the time he addressed himself to a desktop computer screen, where he edited old case notes as mine, such that my print-out included inaccuracies, such as stating that i have no medical allergies (i do, including to some painkillers and anti-inflammatories; moreover, he never actually asked me this question).

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At first the doctor tried to talk me out of getting another blood test (PCR, this time) since it was expensive (true) and since he was so certain i had chikungunya (ass).

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He then spent at least a minute of our already poorly utilized 10-minute appointment slot to denigrate my normal GP, in a mock-humble way that acknowledged him as a junior doctor and my usual GP as a senior doctor — but also that he was much more in the trenches at his location, as opposed to her more posh and secluded (<5 km away) location. (Again, recall these are both part of the same hospital system.) He was seeing all the chikungunya cases and she wasn’t, so he knew how to spot-diagnose and which test to run.

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He then told me that when my test came back positive, as he was sure it would (it didn’t), i should switch doctors. He also poo-pooed her having prescribed me calcium and instead prescribed a multivitamin; he also prescribed a different painkiller + antacid combination for no apparent reason. (i should note that neither doctor actually asked what i was already taking in the way of vitamins before prescribing these to me — i went ahead and bought everything i was prescribed so i could show off the detritus collected for treating a suspected virus over the course of three days.)

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Perhaps to some patients, this kind of confidence and blatant salesmanship are appealing and hearken to days of doctors-as-gods. Not to me. So, at a minimum, as a salesman, this doctor has no idea how to read a customer.

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In fact, his actions seem the very definition of not working in a system or a sign that the system is not working. He could have, instead, said he would call my regular GP and tell her about the extent of the outbreak and about which test to run. Or report it upwards so that there could at least be systemic learning within the hospital system. But, no, he opted to promote himself. And perhaps this is what the ‘system’ incentivizes. But, if so, then what exactly is the benefit of being part of a hospital system if neither my personal records nor basic system- or city-wide learnings can be shared among doctors within and across sites?

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To return to the initial issue of whether healthcare functions as a market, to the extent that it does, people often rely on quality indicators that may not be directly related to accurate diagnosis or perfect treatment (which are sometimes hard to assess from the patient point-of-view). So, there is cleanliness and comfort of the surroundings (the corporate chain does reasonably well on this). There is whether you feel listened to and respected as a patient (fail). Or, if your doctor isn’t particularly nice (we all secretly want to be treated by Dr. House), you should at least trust him or her but neither GP in this case did anything particularly trust-earning (and did some things that were trust-burning from my way of thinking). There is convenience (yes in terms of online scheduling but no in terms of tracking patients through the system).

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And, one would think, there would be a benefit of aggregating learnings and best practices across the system — but this appears to not be the case. The corporates may want to think again about how they are fulfilling quality demands.

 

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going viral in delhi / is diagnosis a luxury (delhi summer illness 2)

In this post, i continue to try to make research and observational hay out of my own illness in Delhi (starting here). As a quick re-cap, there was a week of severe, arthritic joint pain and weakness, which started to let us slightly right when the rash and fever kicked in. Those were mercifully short-lived but the joint pain has continued for over a month.

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When you shuffle (quite literally since my feet weren’t keen on bending and my hips weren’t into a long stride-length anyway) into a doc’s cabin in Delhi and the first words out of your mouth are ‘joint pain’ and it is dengue and chikungunya season, these are the immediate suspects (also here for news of outbreak). One of the doctors i saw  was happy to diagnose me by sight and actually, actively encouraged me not to bother with the (pcr) bloodtest, since (he was a bit of an overconfident ass and) the test is expensive (about INR 5000 or roughly US$ 75 — definitely out of reach for a lot of patients). An earlier doctor had prescribed a cheaper test, which is more sensitive to the stage of the illness (IgM).

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At this point, i have had the two different chikungunya tests, a dengue test, a malaria test, & a parvovirus b19 test, all of which have come back negative. If malaria had been positive, of course, it would have indicated a very different treatment course than any of the viruses. And it’s good to know if you have dengue rather than a different virus because it is possible you may need a transfusion. But at the patient-level, all the rest of these viruses have a similar ‘treatment’ protocol – fluids, rest & painkillers (plus, as it always seems in Delhi, an antacid to pair with the painkiller).

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There perhaps isn’t much reason, then, to explore which specific virus ails you unless you, like me, find comfort in having a named illness rather than a collection of symptoms that could be named ‘a viral fever.’ (Update 9 Oct 2016: unknown viral fevers in Delhi.)

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And anecdotally, some folks in Delhi seem comfortable just saying that they have ‘a viral’ or ‘a viral fever’  or, intriguingly, that they are going to get tested for dengue to see ‘whether it’s dengue or a viral fever.’ (See also the name of the disease and the work of many anthropologists on this kind of non-specificity vis-a-vis underlying causes.) People also don’t seem a lot of stock in the tests — colleagues and at least one of the doctors i have seen feel like i probably had/have chikungunya, blood work .

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Which raises the question of why i have sought so many different diagnostics (yes, insurance covers it) and why a person might do so more generally. For me, i have both a desire to have a name for my diseases and also a suspicion that a virus doesn’t explain the full story of what has been an extended summer of illnesses rather than a single episode. But for a regular patient paying out-of-pocket, beyond sorting illnesses with different treatment protocols (so, parsing malaria from dengue), being able to pin a particular name to the cause of feeling unwell may not be that important — or, indeed, may be a luxury.

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From a public health perspective, though, lack of clear diagnosis means no numbers to report upward, to understand how illness patterns are changing (including with zika looming on India’s doorstep), when there is a legitimate outbreak, etc. i say that without a complete understanding of how my test results in a private, corporate hospital (some of which were sent to a private path lab in Bombay) make it into any sort of public health statistics at all. The current numbers being reported in Delhi and the surrounds certainly seem too low relative to what doctors off-handedly say they are seeing.

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All of this raises a few questions:

  • During an outbreak, should people satisfied with a diagnosis not based on blood-work (if it looks and walks like chikungunya, it probably is)? Is this sufficiently successful to make up for time and money saved?
  • If diagnosis (sorting between viruses, say) has more public than private benefit (since your treatment won’t change and having ‘a viral fever’ seems satisfactory), should diagnostics be subsidized? How, for whom, etc?
  • Can anyone explain to me whether and how test results from the private sector of clinics and diagnostic centers make it to official numbers? What would need to be done to improve reporting and merging of results into city- or state-wide stats?

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  • Would i be more satisfied with a diagnosis of an unnamed virus in the States? Possibly — it’s certainly happened when down with non-specific ‘flu‘ symptoms that rule out the need to treat with antibiotics. But why am i more comfortable with this?

my black folder (delhi summer illness 1)

Since i have lost much of the two months to an extended illness — and since my original reason for getting into public health was unsatisfactory doctor-patient relationships and inadequate assistance helping patients navigate hospital and health systems — it seems to make sense to write about observations and frustrations i had seeking treatment in delhi. i offer this up in the spirit of participant-observation research — not seeking sympathy but trying to point out what is currently not/working. i definitely welcome stories from others seeking health-care in india or elsewhere in the comments: this is a conversation that requires much more attention and probably research.

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There are three disclaimers. First, i am an extremely privileged patient in Delhi and attend one of the (arguably) best private hospital chains in town. So my case should be taken as something of a ‘best case’ in terms of how i am treated and my experience navigating the system. Second, being sick has made me incredibly grumpy. Third, we are still not entirely sure what i had/have. Given the on-going outbreak of chikungunya in Delhi and my symptom set, this is a plausible guess — but in full disclosure, the test for this and multiple other viruses were negative. While many people in Delhi seem satisfied with being diagnosed with ‘a viral,’ not knowing what i have is hugely frustrating.

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Whatever i have, ‘joint pain’ does not do justice to the experience — i have had what i would classify as joint aches or pains in the past and this weren’t it. Overnight-onset arthritis begins to get to the point: too painful to walk properly thanks to weak and angry feet, ankle & knee joints; too stiff and painful to make a fist around a bottle of water and elbows too weak to support the bottle anyway; etc. Suffice it to say, rapid aging it isn’t much fun:

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While this whole illness narrative begins a month back, this blog’s story starts today, as i am preparing to go spend a bit of recovery time with my parents in TX and get a second opinion in the process. My mom is scouting for a rheumatologist there (thanks, mom!). She wondered if i could just have my doctor here in Delhi just fax over my notes so far (because the new doc wants to review them before accepting me?). Well, no.

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Which brings me to my black folder. There is no patient filing system that stays at the hospital for me here in Delhi, though i presume the hospital tracks some sort of information linked to my mobile number in the computers at which people are always tapping (they are very capable of sending via emails the status of my reports or texting to quiz me on my satisfaction).

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Each visit generates quite a bit of paper for which i am responsible, making me in a very tangible way the curator of my health history. i find this slightly stressful and, again, unlike a lot of patients, i can read and comprehend the vast majority of what is in my file (handwriting aside), can sort through and put it in date order, and so on.

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At a minimum in a visit to my hospital, there will be the consultation fee receipt, the consultation notes + script and the receipt for medicines purchased. But, likely, there will also be an additional receipt for diagnostic tests to be rendered and then, at some point, the results of that test, whether it is a printout, a scan, an xray, etc. i have to carry all of these. These papers should be ready at all times. For example, vital signs are recorded on my consultation receipt for imperfectly clear reasons. The receipt is then taken out of my possession (ack! i need to photo that for insurance claims!) to be laid before the doctor, who sometimes notes down my vitals on a fresh notepad before beginning the consultation scribbling. More paper.

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For awhile, one pretends that the soothing seafoam-green envelope proffered by the hospital/clinic along with one set of test results will suffice for the burgeoning ream of paper. But any sort of ongoing illness puts that rapidly to rest. Your makeshift, portable medical record is suddenly and literally coming apart at the seams when you have an extended illness episode, along with your feeling of being able to present your case to another doctor (or to the same doctor, since they have nothing else to which to refer back).

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Now i have upgraded fro a tattered folder to one of those report-type folders with the plastic sleeves built-in — the kind with a tab on each sleeve, which i have labelled with the month. Each month contains all the the august sleeve is pree-tty full but it is doing the job nevertheless. Mostly.

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Over the course of this illness, i have worked to keep everything as organized in this folder as possible as a way of imposing some order on the multiple visits, the multiplying symptoms, the confusing test results and their implications for yet more tests. When your fingers aren’t working properly (or more generally when you are feeling like crap), it isn’t very fun to sort through these papers and supple-ly sliding them into the slippery plastic sleeve. It also isn’t particularly fun to clutch this increasingly sweaty folder while you try to navigate your way through jostling patients, especially when your standard elbows-out strategy has been rendered impossible. Hospitals, as i contend in future posts and as others have said before me, aren’t very easy places to be sick. And, at least in Delhi, to be without a chaperone/Moses.

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But one does carry one’s plastic folder to place before the doctor: see, i am a good patient. A conscientious patient. You can tell because my files are in order that i will probably try to follow your prescriptions and that i get what is going on here. And that this whole thing has been ‘going on’ far too long. We can both see that, right?

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i can’t pinch my fingers properly to pull the sheets out for you but here, this is the August sleeve. You can just pull them out and… sure, spread them all over the desk. Gah, this is the same feeling as when you had the immigration officer with your finger marking the visa page and they insist on closing the passport booklet and then casting you disgusted glances when s/he can’t find your visa. But worse.

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Yes, i could point(-ish) you to what you’re asking about… but rifling through will work eventually as well. Taking a call while you’re looking and while i’m sitting here will definitely help as well. Oh, you’re done? Then, sure, sweep everything back into a haphazard pile and then just… OK, bypass the plastic sleeve. Just close the cover over the whole mess. That’s cool. i just spent 3 minutes explaining how painful it was to work my fingers and i assume you were listening because you prescribed multiple blood-tests and several medications of questionable necessity. You even took notes. Including those notes, altogether, that’s four more pieces of paper i am going to acquire in the next hour. To add to that mess you just made of my medical history. To clutch-ish until i get home and then sort the whole damn thing again after the next painkiller to show the next half-interested doctor that i am a good patient, it’s just that the illness isn’t going away.

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Look, it’s all here in my folder. Dammit. The folder tied the whole thing together.

i feel like an #oddeven party pooper (reducing and working are not the same)

there are two nice, evidence-informed op-ed pieces out today on delhi’s odd-even scheme to try to reduce air pollution (here and here). the results are heartening because i didn’t have a good sense of whether a two week window of implementing a policy — to which there were many exceptions — was long enough to potentially detect a statistically significant change in meaningful measures of pollution. nor, admittedly, did i feel that i was breathing cleaner air the past two weeks. as one the articles points out, much of the anecdotal chatter has been about clearer roads, not about clearer skies.

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since i live in delhi, am certainly affected by the air quality, and worried about my health accordingly (plume tells me every day that the situation is dire), i was pretty pleased to wake up to the headline “yes delhi, it worked.” and what has indeed happened is that good evidence (rigorously obtained, as laid out by suvojit) has been generated of a statistically significant reduction in nasty particulate matter (pm 2.5) (by 18%) during the hours the intervention was in effect.

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this was a policy that i wanted to see work, so i am pleased that the evidence shows a reduction in the particulate matter that is driving many of my good friends out of the city (alongside many other woes). but we must be careful — whether something “worked” is more subjective than is the evidence of a reduction, which greenstone and colleagues have nicely and rapidly documented.

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if models had predicted a 50% reduction, we wouldn’t have been so thrilled about 18%. if the government had said that every little bit counts and that even a 5% reduction would be counted by them as a success and a reason to commit to continuing the program, then indeed, 18% is quite impressive.

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moving forward, as delhi tries to clean up its act and hopefully become a model for the rest of the country, clarifying up-front decision-points and definitions of success will be important. for the next pilots — because delhi desperately needs such measures — how will we declare, in a rigorous and defensible way, that a policy effort ‘worked’ well enough to be scaled and continued?  those of us interested in promoting the use of rigorous evidence and evaluation to inform decision-making need to be slightly cautious in our interpretations and celebrations of victory when we haven’t said up front what we’ll count as a triumph.

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*as an addendum (31 jan 2016), it is not clear that the researchers themselves penned the title ‘yes delhi, it worked.’ for the benefit of the doubt, i am hoping that the researchers submitted something more along the lines of ‘yes delhi, odd-even reduced pollution’ and that the newspaper itself opted to change it. but the point holds that success is subjective and therefore requires a definition, preferentially ex ante.

Aside

delhi’s #oddeven plan had a significant effect on pollution

agree that this is a potentially good sign about individual citizens being willing to engage in collective action – note also that many were most excited about lessened traffic, which is a good reason to think about inspiring collective action in ways that bring about both a public good and a private gain, allowing the pursuit of direct and indirect policy goals. my sense is there is still a long way to go in convincing people that the pollution is a problem and getting worse.

Suvojit Chattopadhyay

Researchers Michael Greenstone, Santosh Harish and Anant Sudarshan have some news for us. Hard data that shows that the Odd-Even plan reduced pollution by significant levels in Delhi. The headline: this study finds there was an 18% reduction in PM 2.5 due to the pilot during the hours that the rule was in effect. The effect size is truly staggering, and is quite unusual for studies that use such rigorous methodology to look at the impact of policy interventions.

Starting January 1, while absolute pollution levels increased both inside and outside Delhi (for atmospheric reasons, as noted by other commentators), the increase in fine particle levels in Delhi was significantly less than in the surrounding region. Overall, there was a 10-13 per cent relative decline in Delhi.

Around 8 am, the gap between Delhi’s pollution and that in neighbouring regions begins to form and steadily increases until mid afternoon. As temperatures…

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nimboo pani: challenges and triumphs

there has been some complaint from some quarters that i have not recently provided any update about my life, reserving blog posts for slightly more wonky topics.

this post will be a small antidote.*

in delhi, one way of dealing with the energy-sapping heat is nimboo pani — literally “lemons water” but in actuality lemonade that is salty and possibly spicy/masala-ed in addition to sweet. (some people add mint but, of course, such frippery is not welcome in this household. i have only recently found a source for basil leaves, which is a far more sensible option.) in this salty way, nimboo pani approximates ORS and can help combat creeping dehydration, which seems to happen even if you are not noticeably sweating or doing anything at all.

i am curious as to why similarly salty lemonades did not catch-on in other hot places, for example, the southern US, which goes heavy on the sweet drinks in summer but, to my knowledge, doesn’t add salt (granted, the food may provide plenty, so things may balance out).

in any case, to celebrate having my flat nearly in order (yes, i know, people want pictures; patience is a virtue), i had a small open-house party at the beginning of july (HOT). i wanted to have nimboo pani on hand but was uncertain how to have ample drink prepared given the constraints of the refrigerator space and the need to have other drinks and food chilled as well.

one small triumph came in finding a shop that sold pre-squeezed lemon juice. nimboo (lemon) here are generally about golf- ball sized and the prospect of squeezing enough to quench thirst for 5+ hours was unappealing, no matter how many martha stewart points i would earn.

my first thought to dealing with the space issue was to make a lot of nimboo pani in advance and then freeze it. this seemed briefly promising until i thought about using salt to melt ice in the winter. this led to a string of probably unnecessarily dramatic texts to pop of the nature “I HAVE  A CHEMISTRY CRISIS.” it was agreed that freezing salty water would be difficult. (it was also likely, tacitly agreed that this was not a crisis.) (follow-up point, auto-correct suggested i might have meant “nimboo panic.” it does fit.)

the ice idea remained promising but how to dissolve all the ingredients on the spot? a friend (thanks, @urmy_shukla!) pointed out that sugar was particularly difficult to mix, given the temperature of the drink. simple syrup presented itself as a solution (ha!). so, in the end, i had frozen lemon cubes and frozen ice tea cubes (in hopes of nimboo pani palmers (go deacs) catching on, but must admit that brown ice has limited appeal, especially in a place where water quality and sanitation are such a serious concerns. perhaps green tea represents a future way forward.) so, people could drop lemon cubes into their glasses of water, which worked out well. i had bowls of rock salt, ground cumin, and ground ginger out so that people could salt and spice their drinks as per their own taste buds. and, i made plain and cardamom simple syrup, which veered slightly towards caramelized but seemed to be ok. this set-up was also good but there is at least one person in our midst who does not agree that drinks should be salty or spicy ever. i may have needed to add a little instruction on how sweet simple syrup is, as @sg402 discovered with VERY sweet nimboo pani.

anyway, party was a success, make-your-own nimboo pani seemed to be a success — so, the world’s problems are nearly solved. basil simple syrup will be pursued in the future.

please do be impressed that i smuggled two public health references into this post.

 

*a problem with blog-writing is that any word can be a rabbit hole. in typing “antidote,” i wondered if at any time “dote” was used to mean “poison,” in which case, antidote would be a sensible word. “dote” in the sense that we use it now, seems to be derived from the word for foolish. etymology.com implies that dotum comes from the greek “to give,” so that antidote was “to give against.” there you go.

 

implementation / a ban on new ideas in India

not a lot of time to write on my own blog but here’s one that i wrote for 3ie based on the recent #3ievalconf in Delhi, Measuring Results.