Transcriber: Rhonda Jacobs Reviewer: Eunice Tan
The World Health Organization has expanded the definition of health
from being merely physical to complete physical, social and mental well-being.
Today, I want to stretch those boundaries a little more
and discuss about three new dimensions of health:
health as an identity,
health as a public responsibility and health as a fundamental right.
As we move from the first to the third,
the audacity of ideas is going to increase
and we are going to enter realms of higher, more provocative thought.
So let’s start with the first one:
health as an identity.
We do know that health is part of our identity,
but can health be our identity?
Case in point: vaccination passports.
Your vaccination status identifies you
and qualifies you for movement from one region to the other,
just like a normal passport.
Or just like a normal passport has certain immutable data points,
like your permanent address, your date of birth,
while there are other dynamic data points,
like your visa status or your temporary address,
your vaccination passport can actually have certain static elements,
like the vaccinations you have had as a child,
and some dynamic elements, like flu vaccines, COVID vaccines, etc.
So whenever we are using health status to identify you,
health becomes your identity.
And this is not the first time in human history that we are doing this.
During the Second World War,
German soldiers had blood groups tattooed on their bodies.
This is still a common practice,
to have blood groups mentioned in dog tags or other military apparel, like uniforms.
If you notice carefully,
your driving license also has your blood group mentioned on it.
Now, why is it important?
In case of a road traffic accident,
information like this can save precious time in the emergency room.
But does your doctor know about your diabetic status
before pumping in glucose?
Does the emergency doctor know about your HIV status
before asking his team to jump in with normal levels of safety protocols?
All these are fragments of your health identity
and are extremely vital to determine the outcome
of the clinical services that have been delivered.
Another very common example is disability certificates.
We identify individuals with special needs
and provide them the services that are required for their condition.
So there is ample evidence for massive gains to society
from maintaining a comprehensive health identity.
But then the question arises
of why haven’t we made it mainstream till now?
So there are primarily two considerations.
The first one is, like I mentioned,
the health identity has a static part and a dynamic part.
For the ID to be relevant,
each and every health event needs to be codified
and updated on the health identity.
Now, think of how complex this is for a country like India.
For every health event, whether you’re going to the dentist,
you’re going to the OPD or going for a flu shot,
each of these events occur in a different setup -
it can be a public setup or a private setup -
and your data is housed in each of these different setups separately.
Reconciling all of that into one universal, longitudinal health record
is the Holy Grail for healthcare data.
Seems impossible to be done,
but the good news is that in India,
we have already taken the first step towards it.
In August 2019, the National Digital Health Mission has been announced,
which envisions a complete digital ecosystem for all healthcare transactions,
connected to one unique health identity for every citizen.
This is a tectonic shift in healthcare operations in India
and probably will open the floodgates of opportunities for innovations
in the days to come.
Now, let’s try and understand the implications for this
with two scenarios.
The first one:
A patient is wheeled into the emergency room
from a road traffic accident in an unconscious condition.
The ER doctor searches his belongings and finds his health ID there.
He logs on to a central system
and uses his license number to gain access to his emergency records,
figures out the blood group of the patient,
that the patient is diabetic,
understands that the patient had epilepsy,
which very well might have been the cause of the accident in the first place,
and that the patient has recovered from COVID in the last 15 days.
All of these data points are extremely crucial
and can make a huge difference in the outcome of the clinical care
when it is known versus unknown.
Let's look at another scenario of buying health insurance.
Let's say you and me, both of us want to buy health insurance.
We are of the same gender, similar age category,
but your lifestyle is much more healthy than mine.
You sleep better, you have a better work-life balance.
So the chances are
that your health insurance premium will be much, much lower than mine.
And this would be actually calculated
by the insurer fetching your health ID and figuring out a health credit rating,
which is very similar to a financial credit rating,
which allows you access to certain financial instruments
based on your financial health and history of financial behavior.
Similarly, a health credit rating can provide you much lower insurance premiums
based on your health behavior in the past and your current health status.
Now that we understand the benefits of having a health ID,
we also need to be cognizant of the fact that information can be misused.
Whenever in human history
we have classified individuals based on identities,
like visual identities of race and color,
non-visual identities of language and religion,
we have seen that while people garner a lot of support from within the category,
there is dissonance between categories to the levels of ostracization,
which is why it is extremely important that the health ID be protected
and be revealed only to people on a need-to-know basis
with consent from the user.
This brings me the second consideration
of why it is challenging to implement a health ID.
Let me start by giving an example.
How many of you would be comfortable in sharing your school or your workplace
with people living with HIV?
Even if I tell you that the chance of contracting the disease
is less than 0.00036 percent,
what you would hear is “chance of contracting the disease.”
This is also largely because as humans, while in theory we understand probability,
it does not always translate in action.
Whenever we are making decisions,
we might disproportionately overestimate the hazards,
especially when it comes to health.
That is why it is extremely important that in the health ID,
certain parts be mandated to be revealed by policy,
while others have to be guarded and protected,
only to be revealed to people on a need-to-know basis
with consent from the user.
This idea has been taken very seriously
by the architects for the National Digital Health Commission,
who have placed user consent at the core of the design of the health ID.
As we move into a new world of genetic information,
we also move towards the possibility of creating the ultimate health ID.
The uniqueness of your DNA when connected to the health ID
makes health an indisputable part of your identity.
But with this, we also venture into a world of much more difficult questions.
For example,
would you still choose to be a surgeon if you had known that you have a gene
which has a high chance of spinal muscular disease in the future?
Would you still live in the cities
if you had a gene which had a propensity for lung cancer,
knowing that city air is relatively poorer than countryside air?
Would you still marry the person that you love,
knowing that the compatibility
of your genetic components on the health ID
do not guarantee a healthy progeny?
Let’s take it a bit further.
Would you match your health identities for genetic compatibility
before dating someone?
All of these questions do not have a linear answer
and are quite complex by themselves.
But what they do have is give us a sense
of the comprehension of probability, choice and identity for us as humans.
These are all fragmented parts of your health identity,
and this information is there.
How you use it is up to you.
Which brings me to the second dimension: health as a public responsibility.
In more general terms,
it basically means that the health of the individual
is as much the responsibility of the society
as the health of the society is the responsibility of the individual.
A common example we have seen during the pandemic
is self-isolation on contracting the disease.
Many people who tested positive self-isolated themselves
to protect the rest of the society from contracting the disease.
Very soon we’ll have some identities, like vaccination passports,
regulating mobility in high population areas,
like airports, swimming pools, malls, etc.
Some of us already have seen this with the Aarogya Setu app in India,
where the app was used to control mobility into high population areas like malls.
Many countries in the world, during the pandemic,
have controlled mobility based on not just the health status of the individual
but also mobility data on where that individual has been.
If they have been in areas of high infection probability,
their cumulative health score makes them at a risk for the society
and their mobility is managed accordingly.
For all these operations to happen,
the fundamental building block required would be some version of a health ID.
And in the near future, the same health ID can be used in further use cases
where we influence the health of society.
For example, should your smart car, based on your health identity,
decide whether you should be able to drive on roads or not
in case you are an epileptic?
Let’s say you are out on a hike.
Should Google Maps, based on your health identity,
decide which route you should take based on the condition of your arthritis?
Let's make it a little more provocative.
Should vaccinations be made mandatory as a social responsibility?
Again, these are questions which might not have a linear answer today,
but what they do exemplify
is the influence of us as individuals on the health of the society,
and the influence of society on our health.
Increasingly, more and more cities are including the health perspective
in urban planning.
How do we design cities such that there are no food deserts
and every point in the city has access to fresh food?
How do we design cities so that each point in the city
has an access to an emergency room in under 15 minutes?
During the pandemic, we have seen cities respond to a healthcare situation,
and going ahead, there’ll be a pandemic mode of operations for cities,
where schools, stadiums, high volume areas
will be pre-earmarked for makeshift quarantine centers if the need be.
Police and firemen will already have pandemic mode drills.
Public transport will have a pandemic mode of operation,
respecting social distancing.
Schools might have a pandemic mode of operations,
which is a hybrid of offline and online interactions.
So the cities will start investing in their healthcare more and more.
Just like good neighborhood schools influence the real estate prices
for the areas around them,
a similar trend we can expect for hospitals,
where access to healthcare will be a factor
increasing real estate prices in and around hospital areas.
We have already seen some cities investing in healthcare much more than others.
For example, some municipal corporations in India
had a global tender for vaccines outside of the central ration of vaccines
which they would receive from the government anyway.
This basically shows us how richer municipalities
can actually invest more in their healthcare
and ensure that they attract the best citizens based on the same.
But this, again, brings a question of equity.
If health is a public responsibility,
who is accountable for equity between richer cities
and relatively poorer ones?
Which brings me to my third perspective:
health as a fundamental right.
In the recent past, how many of us have actually felt helpless
when we did not have an ICU bed when we needed one?
More than the first wave, during the second wave,
almost everybody, in their first- or second-degree connects,
know people who did not get access to an oxygen bed or an ICU bed
when they needed it.
This begs us to think
that shouldn’t our lives be protected not just by the police and the military
but also by access to ICU-level care when we need it?
Right to health is not an explicit fundamental right
within the Constitution of India.
It is nested within the Directive Principles of State Policy.
Time and again, the Supreme Court has, through various judgments,
made sure that the right to health is implicit within the right to life.
But then again, it is not enforceable in the court of law
since it is not an explicit fundamental right.
There are primarily two schools of thought regarding this.
One which says that health needs to be made into a fundamental right
and be moved from the State List to the Concurrent List
so that the accountability of healthcare is with the state government
as well as the central government.
This helps especially in pandemic situations,
where some decisions can only be taken by the central government.
For example, opening and closing of international borders,
international trade for essential commodities, etc.
While the second school of thought says that bringing the center in
will increase a layer of bureaucracy,
leading to longer response time in terms of emergencies,
and states have done fairly well in containing outbreaks in the past.
Case in point, Kerala during Nipah virus, meningitis in UP and Bihar.
So both models have their own pros and cons,
and there’s no consensus to go ahead with any one particular way as of yet.
But what I would urge you to think
is that do you feel strongly enough about your right to health
as much as you do about your right to life?
Are you equally aggravated when you do not have an ICU bed when you need one
as you are when somebody assaults you and breaches your right to life?
If not, what would change once you do start demanding
the same level of rigor for health from yourself and your governments
as you do for protection of your life?
At this point, I would like to bring it to a wrap
by reiterating the three perspectives: health as an identity,
health as a public responsibility and health as a fundamental right.
I would like to leave you with the thought of what would a future look like
where health is an identity, health is a public responsibility
and health is potentially a fundamental right.
What would be the opportunities and innovations in a future like that?
What would you create and contribute in a future like that?
A future which actually began more than a year ago.