If I were to take a poll of the political inclination of the fellow Indian Americans that I know, they would heavily lean towards the Democrats. While I have never actually conducted such a poll , the slant seems quite apparent to me. Politically the Indian American community overwhelmingly votes Democrat. This result is actually quite surprising when you look at it in the light of the India-US relationship. The following contradictions start to emerge. The Bush-era has been the high-point of the India-US relationship. Secondly, two trends important to Indians – the growth of a vibrant Indian tech community in the US and the economic boom that India enjoyed in the last 10 years have been a direct result of Republican policy. So if the Republican party benefits India more, then why do Indians sit so squarely in the Democratic camp?

Before we explore possible answers to this question, let us first understand the assertion I made about the Republican party being more beneficial for India. India has dramatically changed in the last 25 years. Long gone are the days when you had to wait in line for multiple years just to get a landline or when a refrigerator was considered a luxury item. Today your street peddler, fish monger and your maid servant all carry cell phones. India has enjoyed a huge economic boom in the last decade. The seeds of economic prosperity were planted by the Rajiv Gandhi government in the late 80s. These economic liberalization policies were cemented in place in 1991 by the then Finance Minister Manmohan Singh, who did away with the License Raj, deregulated businesses and allowed foreign investment and encouraged private enterprise. In short, India moved from being a socialist economy to a capitalist one. Since then subsequent governments have continued on the path set by these reforms despite opposition from the Left. This has transformed the Indian economy from being virtually stagnant to the second fastest growing major economy in the world, next only to China.

A large part of the growth in the Indian economy is from software (IT) and outsourcing (BPO). Since circa 2001, these two industries have seen exponential growth as US industries off-shored many of the their jobs. Almost every big US tech company has a large presence in India. BPO which was practically unheard of, when I emigrated from India in 2000, was all the rage in just a few years. During this time many Indians chose not to pursue careers in the US and instead follow equally lucrative career paths in India, and many people from the Indian American community chose to migrate back to India due to the economic boom. This boom was partly influenced by the business friendly policies followed by the Bush government. The Bush administration viewed India as a strategic partner and actively encouraged BPO by way of tax breaks and other incentives. In contrast, Democrats are seen as protectionists by the Indian government and media. Obama who has been an outspoken critic of outsourcing, has repeatedly made demands to end tax breaks for companies which outsource jobs. Recently, the Democratic governor of the state of Ohio banned outsourcing, which was condemned heavily in the Indian media. On the other hand, the news that Senate Republicans blocked an anti-outsourcing bill was met with much jubilation.

Another factor is the growth of the Indian tech community in the US. The Indian tech community in the US is relatively young. The growth of this community started with the Y2K and dot-com booms in the late 90s. One of the sticking points for this community was the limited availability of H1B visas. More than a third of all H1B holders are Indian citizens, and most of the Indians in the Silicon valley, New York, Seattle and other tech communities have immigrated on a H1B visa. So a smaller cap adversely affects the Indian community in the US. To encourage growth in the tech sector, senate Republicans pushed to temporarily increase the cap on H1B visas from 65000 to 120000 despite opposition from the Democrats, labor groups and even a veto threat from Bill Clinton. This cap was further increased during the Bush years before it went back to the original number in 2004, despite Bush urging a Democratic Congress to extend them. Most recently, the Obama administration has increased the fees on the H1B visa in a move to discourage its use. Historically, the Republicans have generally been in favor increasing or eliminating the cap while Democrats and labor unions have generally been opposed to it. Leaving aside the politics of this issue, the Indian community has greatly benefited from this program and the subsequent pushes to increase the limits.

Besides direct correlation to the tech sector, the Bush administration has been beneficial to India in a number of other ways. This includes signing of the nuclear deal without subjecting India to the NPT. India has steadfastly refused to sign the NPT, which the Democrats view as a necessity. Such a deal could never have happened with a Democratic administration. Besides that there were a number of bilateral deals for improving trade and co-operation between the two countries. It is unknown whether the Obama administration will continue a similar approach. The present administration is far more interested in China and Pakistan, to pay enough attention to India. The upcoming Obama visit to India will decide how the administration’s India policies shape up in the future. Of course, some progress can be expected despite the sticky points.

So if Republican presidents and congresses are generally more favorable for the Indian community, why does it lean Democrat? I do not know the answer, but let us explore a few possibilities. The first possibility is that even though Republicans are economically more liberal (also called economically conservative in US parlance) they are socially very conservative. But, the average Indian is typically far more conservative than the average American, especially on issues such as gay rights, abortion, role of religion etc. So this theory does not hold water. Another plausible explanation is a sample bias. The Indians I tend to associate with are the ones who migrated to the US in the last 10 years to do their schooling and started their careers fairly recently. They also tend to be socially more liberal. Since younger and less affluent people lean Democrat, while older and more affluent ones lean Republican, this distinction could just be due to a sample bias. But this explanation does not account for the behavior of the Indian tech community as a whole which has been around longer and is considerably affluent. An alternative explanation which is a bit more satisfactory to me, is that a large part of the community spent their formative years in American politics during the Bush-era. While the Bush presidency was good for India, with two unpopular wars, and a belligerent foreign policy, it was not a very good administration for the world. This may have left a lasting impression on the populace causing it to sway Democrat.

What are your thoughts? What could be the reason for this apparent contradiction? Regardless of the reason, I find it strangely surprising and irrational that Indian community seems to sway towards the party that benefits them and their countrymen the least.

In the previous post, I outlined some of the drawbacks of Scrum as a software process. One of the reasons that I mentioned, but did not elaborate on was that Sprints result in a lack of solid software. In this blog post I’ll discuss that issue in more detail.  Awareness of these issues which can and do occur in Scrum makes it possible to come up with effective solutions to combat them.

In my opinion, the primary reasons why software quality suffers in Scrum are as follows:

1. Lack of proper design
2. Artificial deadlines
3. Community ownership

Lets start with how software design is handled under Scrum. The design task is one of the hardest to plan for within a Sprint. In fact, Scrum assumes that the design should be completed before a project is even planned. This works only in teams where someone else provides a functional or technical document describing what needs to be done. At every place where I have worked, that has never been the case. The process of designing software is highly asynchronous, involves lots of external dependencies and is difficult to estimate. When using Scrum, people typically follow one of two approaches – including design as a separate story in an earlier sprint, or bundling design and implementation in the same sprint. The first approach works better in practice, but is harder to coordinate. This is especially true when Sprints are longer than 2 weeks, as it creates an unnecessary artificial gap between the design and the implementation. The implementation cannot be scheduled until the next Sprint and sometimes may have to be de-prioritized until the following Sprint or sometimes even later.

The second approach to design, viz. bundling design and implementation as one story, is more natural to execute but is more problematic. The pressure to finish both design and implementation by the Sprint deadline provides little incentive for the developers to complete the design properly by engaging all the stakeholders. For example, after two of our projects were delivered our stakeholders indicated that this was not usable for their purposes, resulting in both the projects getting no usage. The reason for failure was that the customers were just not asked for input during the design phase. The team had two choices either finishing off the implementation with a design with limited external input, or waiting for input on the design but be idle during that phase as nothing else was scheduled for the Sprint. The team obviously chose the former approach. This example is a bit extreme, but even for simpler tasks I have seen that people tend to jump into implementation sooner than they should have, if both the design and implementation are scheduled in the same Sprint.

The next issue is that of constant artificial deadlines. Recall that Sprints are planned 1-4 weeks at a time. At the end of a Sprint, the team is expected to complete everything that they planned on. This is almost never the case since either the plans are too optimistic or the team gets waylaid by other problems. When faced with too many deadlines, developers tend to take shortcuts. This primarily manifests itself as missing or inadequate unit testing. But sometimes it also means that a developer will skip a better solution for a hack just because it would have taken them a few more days to implement the better solution resulting in them missing the deadline. That leaves unnecessary broken windows in the code and repeated deadlines leave the code in an extremely vulnerable state. In one of the teams, we had to completely throw away a code base built over a couple of years as it was damaged beyond repair. Constant use of hacks and lack of testing made the code was impossible to modify without causing any regressions. Even after the team spent 6 months fixing bugs it could make little headway. We rebuilt the code base in six months after we dropped Scrum and concentrated on building a solid product instead. While code rot is a common phenomenon in many projects, it seems to be exacerbated when using Scrum.

The last issue is that of community ownership.  In Scrum, the entire team owns the software and not an individual. While this ensures that tribal knowledge is spread around, it also means lack of individual responsibility and accountability. I firmly believe that developers should have complete ownership of the software they write. That means if they release software with bugs, they are responsible for the support and fixing the bugs or to put it in simpler terms – “Everyone must clean up their own shit.”  Lack of individual ownership causes people to throw poor code over the wall to others. There is no one clear individual who is the goto person for a particular functional area of a piece of code. Rather everyone makes patches everywhere. This was another reason our code base was unmaintainable in the aforementioned team. Sprint planning allowed for any developer to pick up any task, and rather than steering a task to the best person to make the change. This made it a predominant practice to have one developer fix bugs left by another instead of having that person go back and assume responsibility for that code.

As with the drawbacks mentioned in the earlier post, none of these issues are insurmountable or even endemic to Scrum. The important thing is to realize that these are genuine problems that can become significant issues if not addressed soon enough. Once you are aware of the potential drawbacks, it makes it a lot easier to avoid them. In a future post, I’ll outline some guidelines to avoid these pitfalls within the context of Scrum.

In the past few years, I’ve worked at various companies which used Sprints to plan their work. Agile methodologies, such as Scrum, have become the latest fads in software development. Every company I’ve interacted with touts how they switched to the Agile software development processes and it is the most frequently cited silver bullet for many establishments. There are many processes that the agile methodology advocates, but the one that is being adopted most rapidly is Scrum. You can find innumerable books, websites and blogs that will extol the benefits of Scrum, but any criticism of the process is really hard to find.

Scrum has many advantages similar to those of other iterative or rapid development processes. But due to the high popularity and the heavy marketing of Scrum as a panacea, very few people realize the potential drawbacks they could encounter. This post describes the various issues that I have observed in the companies that I worked at. I will not go into the details of how Scrum works, you can find many great resources on scrum websites. However, my favorite of post on agile is Steve Yegge’s sarcastic post on Good Agile, Bad Agile.

So what are the drawbacks of Scrum? The two symptoms I’ve seen commonly are:

1. Sub-optimal execution
2. Lack of solid software

Sub-optimal execution is any activity that results in rework or unnecessary wasted effort.  In this post I’ll concentrate on the this issue.  A follow-up blog post will delve into details of why Sprints may lead to poorer quality software. Let us look into some of the aspects of Scrum that could lead to sub-optimal execution:

No Longer-term Plan

Sprints are typically planned to be a 1-4 weeks long.  Many, in fact I would say most software development projects cannot be completed within this time frame, especially when they involve changing your core architecture or something deeply technological.  While sprints do a really good job of taking a fraction of the project and making sure it is completed in the allotted time period, what they lose out on is figuring out how the various pieces of the project fit together into a final deliverable. That aspect typically gets overlooked or mismanaged and people tend to forget tasks that are needed for the project to complete. Often these tasks are discovered either at the last possible moment or after deployment, and in both cases need some amount of scrambling and rework. The primary reason for things to fall off the plate is because there isn’t a well laid out plan and a person responsible for executing on it.

Another way the lack of a plan affects a team is when the team ends up consistently focusing on short term deliverables (week – 2 weeks) rather that coming up with a longer term (1-2 quarters) road map. This happens most often in teams with a large influx of high priority requirements. Sprint planning focuses on immediate delivery and that leads the team to deliver on requirements which provide immediate benefits rather than investing in longer term projects which don’t have an immediate payoff but will provide greater benefit a few sprints down the road. While this is not a drawback of the process itself, since a team can consciously avoid this pitfall, it happens as Scrum unconsciously forces people to think in a certain way.

Excessive Time Spent On Software Estimates

During each sprint a team loses up to 1-2 days per developer in planning. The big reason for this is that many teams spend a considerable amount of time on estimating how long it would take for them to complete the planned tasks. This tedious process involves taking a particular story (project) and breaking it down into bite sized (0.5 – 1 day) tasks and estimating them (typically in hours). Software estimates by their nature are almost always overly optimistic and especially so at a granular level. So spending several hours generating incorrect data and using that to determine an exact plan is just time ill-spent. Moreover, the team will often not finish what was planned, and so the additional effort that was spent during planning is wasted. An unfortunate side-effect of this process is that it causes unnecessary friction with management which believes that the team should always complete what it has promised.

As a workaround to this problem of optimistic estimates, people have added bizarre concepts such as ideal days. But ideal days are equally hard to measure and justify and more often than not estimates are still just as wrong. The problem is not with using estimates, almost all software processes use estimates. The problem is spending considerable amount of time on generating an extremely tight plan that leaves no room for the unexpected and is rarely what happens during the Sprint. Another complication that arises from this planning process is that if you err too much on the side of caution, it often leaves people with nothing planned to work on. This is more common near the end of the sprint if the tasks get over quicker than expected, or if people are blocked on certain tasks and have none other. Finding the right balance in the plan is incredibly difficult as it can vary widely from Sprint to Sprint and leads to sub-optimal use of time in either case.

Artificial Deadlines

Sprints are designed to finish all the planned work every few weeks. This results in recurring constant deadlines which are artificial and have very little direct correlation with external deadlines. Constant deadlines in themselves are problematic as they add unnecessary stress on the development team. But they also lead to poor decision-making since the deadlines are fixed in time and not related to how long it takes to deliver the projects. I have seen the following situation innumerable times during planning: A developer estimates a project to take 6 days, but there are only 5 more days left to plan in the Sprint. In a natural process the developer would just work on it and release the software a few days after the Sprint deadline. But not so in a Sprint, due to the constraint that a team should always finish what it has planned in the sprint, the planning process takes one of the following choices. Either the scope is reduced to finish in 5 days, or the project is substituted with another of lesser priority, or an additional person is assigned to the project. All of these decisions are sub-optimal and driven by the fact that the plan should always finish by the given date even though, a release a few days later would have made absolutely no difference to the stakeholders.

Other causes

There are a few other reasons which result in poor planning. One being the lack of continuity between sprints. There is little correlation between the work done in two consecutive sprints and projects rarely get planned correctly across Sprints. This can sometimes result in half done work left lying around or projects skipping sprints, requiring additional effort to restart on them. Another one is the requirement of homogeneity in the team. Scrum assumes that all developers are interchangeable. This is not true, especially in cross-functional teams – some people might be Javascript/CSS gurus, others might be backend developers, some may be QA engineers – each person in the team likely has a unique skill set. Asking people to work on aspects that they are not skilled at is sub-optimal, and planning work based on the composition of the team adds more difficulty to an already complex planning process.

Conclusion

Many of the issues I have outlined can be avoided by a team with some conscious effort. This leads people to argue that these are problems with the implementation and not the process itself. Any Agile Leader will tell you that a lot depends on how the Scrum process is implemented – and if implemented incorrectly it could be worse than the existing process. The first thing they ask when you express displeasure with the process is: Did you follow the process exactly as the book says? And when you say no, they would be quick to point out that it is exactly why the process failed for you. But of course no one follows the process exactly “by the book”. Each company that I’ve worked at had their own implementation based on their internal constraints. And while you can reasonably conceive of implementations of Scrum which do not these problems, the reason teams tend to fall in these traps is because the Scrum appears to promote a certain pattern of thought where it is natural to make these mistakes. Thinking differently and avoiding the pitfalls takes effort and the realization that there are better ways to structure your software development processes.

Teams are building the product for the long-haul and using Scrum is akin to a person running a marathon by sprinting for a few hundred meters and then resting and re-planning what they do next. There are very good reasons why marathon runners do not sprint until they have to at the very end of the race.

While the exact nature in which the provisions of the law will affect the health-care market is something that remains to be seen – people have made strong predictions of the outcomes – the liberals have the rosy ones and the conservatives the scary ones, and some people have even thought of ways to game the system. My guess is that the real outcome will probably be somewhere in the middle, largely leaving the current macro trends such as rising insurance premiums and health-care costs unchanged and that health-care would again be a significant issue in the 2020 presidential elections.

One thing that this law doesn’t do – which in my opinion should have been the primary thrust of any health-care reform – is to make any attempt at controlling the costs. I’ve previously argued that the main way to combat the rising costs would be to move away from a third-party pay system. Imposing arbitrary mandates or shifting the costs to tax payers doesn’t work. Take a look at the data coming out of Massachusetts. MA is the only state which has a similar health-care law – and it hasn’t improved the access to health-care. Moreover the premiums in MA continue to rise while the insurance industry is making significant losses. The administration in MA believes that imposing arbitrary mandates on the rate of growth of premiums is somehow going to limit their increase – and it seems keen to apply various kinds of band-aids to their law which never attack the core issue – lack of competition driven by consumers. The rest of the nation is bound to see similar problems in the coming years as the various provisions of the reform come into force.

I still do not understand why Obama pushed so hard for this reform in spite of strong opposition to it. It is not the liberal paradise of universal coverage that he had promised his voters, but rather some compromised monstrosity written to appease all kinds of special interests. In fact it is a law explicitly written to so that they can have something on paper which can be modified in the future to make it better! Moreover, Obama managed to push the law through using an obscure political process after the Dems lost the MA senate seat and not giving it the due process and consideration it deserved. The perception (especially when it was passed) is that passing an unpopular law will result in the Dems losing the house and the law will get repealed next year. I somehow doubt that is going to happen.  Even if the Republicans win the house (which itself is unlikely), repealing this law would be significantly harder than enacting it.

Unfortunately, this will not be the end of the health-care debate. Instead, what has happened is that addressing of the core issue of rising costs has just been pushed out by a decade. What we ended up with is a stop-gap law which really doesn’t change much, but rather enables Obama to say that he kept his political promise of providing universal health-care during his reelection campaign.

We’ve been searching for a pre-school for my daughter and in that process I started to discover more about how the school system works in the US. And the more I learn about it, the stranger I find the system here. Now, if this system actually had better outcomes then I would have tried to make myself like it. But given that the US education system is considerably inferior to the rest of the education systems in the world, I find it surprising that most Americans like and support this system.

Especially given that in India, where I did my schooling , the education system is vastly differently. There are three kinds of schools in India – publicly funded, semi-private (publicly funded but privately run) and private. While this sounds similar to the US public, charter & private schools on the surface, the demographics that these schools cater to are vastly different. Public schools in India are targetted towards poor & low income families. These are for people who would not normally send their children to school and given the vast illiterate population in India these are crucial for educating the masses. But most people (upper & middle class city dwellers) would not send their children to these schools, and the cities are dominated by people educated in private schools. In contrast, most American students are a product of the public school system.

The big differentiating factor is school choice. School choice is extremely important in India. My parents tried really hard to make sure I get into one of the top schools in the city. And it makes a huge difference – most successful people would come from the top few schools in their city. And so while some of your neighbours’ kids may go to the local neigbourhood schools, they are just not likely to be as successful. Schools compete for the attention of parents – regularly advertising their results and test scores. That’s the one thing that I find sorely lacking in the education system in the US. There is complete lack of competition between schools and a choice for parents. While private schools do offer you the choice, they are almost guaranteed to break the bank unless you decide to have only one child or are a C-level executive of a large corporation.

And while I do not oppose the use of public funds for education, the choice in the public education system is very very limited. You are forced to send your kids to the one public school which serves your area. And while some school districts have choice schools which is good, they are still limited by school district. I just cannot send my children to the best public school in the neighbouring district even if it is just a 10 minute drive for me. The only option would be to pick up and move to a location which is served by a better school, even if it may be just a mile away. That in my opinion is absurd. And it has unintended consequences. House prices are strongly correlated to the school district. Areas with better public schools are just more expensive to buy houses in and affluent areas tend to have better schools. This completely goes against the philosophy that public schools started out with – to provide a good education for all irrespective of your race or financial status. Low income families, most of whom cannot afford to live in neighborhoods with good schools, are forced to send their kids to failing schools and cannot provide their kids with a good education. So this system just ends up exacerbating the issue it is trying to solve and in the process provide a worse education for all.

Moreover laws like No Child Left Behind, make matters worse. Since public funding is controlled by metrics such as standardized test scores, it is in the school’s best interest to inflate grades and dumbing down the curriculum to the lowest common denominator to make them look better on the NCLB scale. The standardization of tests lead to no differentiation of students as every one is treated with the same metric in mind.  Everyone has different aptitudes and they need a different focus in their education. Measuring everyone on the same yardstick does not provide the individuals the right areas of education they need in order for them to be successful in life.

Instead of ad hoc metrics determining the funding of schools, the system should let parents & students determine the funding based on their satisfaction with the school. Parents can do this by choosing what school their children go to. This is the cornerstone of the School Choice movement. Unfortunately this idea has not gained much political traction in the country. There is still a strong opposition to school choice from the liberals and the teachers unions who argue that it will cause decrease in funding for public schools while not improving the education standards!

While the best way to implement school choice (through vouchers, open enrollment, charter schools etc.) may still be open to debate, there is no doubt that empowering parents to make school decisions about their children will make the whole education system better. And though education does not seem to be as pressing as other issues like healthcare on people’s minds, building generations of poorly educated people is not good for the country’s health in the long run.

Rapid increases in the costs of health care in the US has placed an undue burden on small businesses, the self-employed and the uninsured, and the system is need of an extensive overhaul. The White House health care page has an excellent description on the goals of such a comprehensive reform. While the goals themselves are noble, and no person should be denied health care or have to go broke just because they became sick or had an accident, the lawmakers seem to have forgotten the true goal of the reform viz. make health care affordable for all.

The administration’s proposal for cost reduction involves setting up a massive public insurance plan which will be able to negotiate lower payments to doctors and hospitals. But, past experience has shown us that government involvement and socialization does not result in lower costs. Medicare, one of the government’s largest social programs is already running into budgetary difficulties despite the fact that it negotiates far lower rates with medical providers than private insurance. Moreover, similar reform has already been enacted in Massachusetts, and yet we still see rising medical costs there.

Why are these costs rising? In a previous post, I had argued that the reason costs in India were under control was due the presence of free market competition amongst medical providers. By contrast, in the US, neither the provider nor the patient has any incentive to decrease the cost, as all of it is borne by someone else i.e. health insurance. In fact, both have an incentive to increase the cost by ordering unnecessary or more expensive tests – the provider gets paid more while the patient believes that they are getting better treatment. Obama’s plan does little to change this fact. All it does is transfer the cost from employers who pay the premiums (which is indirectly transferred to the employees in terms of lower salaries) to the tax payers.

The dilemma that health care reform needs to contend with is how to provide universal health care without creating a sense of entitlement in the society. These are two opposing forces and need to be balanced. Any health care reform intending to reduce cost must incentivize the system to do so. There is no better way to do that other than giving customers choice of providers based on cost and quality. Free market competition has many benefits – it reduces costs, improves efficiency and spurs innovation. In an excellent article about what’s wrong with the US healthcare system, David Goldhill cites an example of how the free market has reduced the cost of Lasik surgery. In the past decade, this cost has reduced by over 80%, primarily because Lasik is not covered by insurance. Consumers pay for this surgery out of pocket and are deeply sensitive to price changes. On the other hand, the cost of older technology like MRI scans has not significantly reduced as the cost is never directly exposed to consumers.

The following is a list of proposals to re-introduce competition amongst medical providers while still providing universal care. Many of these are based on sources such as David Goldhill’s article, John Mackey’s op-ed in the Wall Street Journal, and the Singapore health care system.

• Provide catastrophic insurance to all individuals. This insurance should cover any basic medical expenses incurred by the individual above $20,000 per annum. Have strict guidelines on what procedures this insurance will cover. Only procedures with a high cost-benefit ratio to lengthen life or improve quality of life should be included. Any experimental, cosmetic or unproven procedures should be performed at the individuals own cost.
• Reimburse the $20,000 deductible to underprivileged sections of the society who cannot afford it. The people below the poverty line should have the deductible fully reimbursed and the reimbursements should be phased out after 400% of the poverty line.
• Make all medical expenses tax deductible.
• Eliminate mandates on employers to provide health care coverage. Eliminate tax exemption for employer provided health coverage, and tax it as regular compensation to the employees.
• Radical transparency – force medical providers and private insurance companies to publish their prices so that the consumer can shop around for the best rates. The government sponsored catastrophic insurance provide detailed statements of expenditures to the tax-payer for accountability.
• Enable any individual to open an HSA account just like an IRA account which would grow tax free as long as the money is used for medical expenses.
• Allow individuals to buy private insurance to supplement/replace the basic catastrophic insurance at their own cost. This insurance could be used to cover some of the initial $20,000 deductible or provide coverage for additional procedures.
• Remove restrictions on private insurance on who or what they should cover, like mandatory coverage for preventative care and forced inclusion of pre-existing conditions.
• Actively encourage and educate people to save in their HSA accounts and seek out primary care on their own.
• Phase out Medicare over time and move seniors to the same plans as everyone else.
• Reform the tort system. Only gross or criminal negligence should result in medical malpractice lawsuits. Medicine is not an exact science, and reasonable advice from the doctor should be trusted.

This plan shifts the cost of the treatment from the insurance provider to the patient, while the safety net of catastrophic insurance protects people from bankruptcies due to illness. Giving the patient more choice would increase competition amongst medical providers and urge them to reduce costs and provide better care. Businesses would not be required to pay for employee health insurance, though they may provide it as a perk, and employees have the choice of just relying on the catastrophic insurance or buying a private supplementary health plan. The one deficiency in this plan is that hospitalization costs which typically run over $20,000 would not be subject to the same competition as lower-end services. There would definitely be some trickle down effect as costs of cheaper services decrease, but costs of expensive procedures would need to be controlled by the insurers pushing back on the providers. This is unfortunate, but as I stated before, providing universal coverage and eliminating entitlement are opposing forces and they need to be balanced.

Unfortunately this proposal is way outside the political mainstream viewpoint. Most lawmakers are in favor of increasing the presence of the health insurance industry, while what I am advocating is to drastically reduce the role that health insurance plays in health care. Until they realize that health insurance is the problem and not the solution, we will not see any dramatic reductions in health-care costs.

Update: This article is featured in the Health wonk review for Sep 2009.

Recently, the Indian cabinet approved a 50% reservation for women in Panchayats, while the bill for 33% reservation for women in the parliament still languishes on the back burner due to opposition from the left. Reservations for minorities or women have been a contentious topic in India: there have been numerous protests in the past when reservations have been proposed and this one is no different. In spite of this, no political party ever seems to have considered any alternatives to reservation to solve the problems for the underrepresented classes in society.

The number of women parliamentarians in India is abysmally low with only 10% of the MLAs being women. The women’s liberation movement wants this bill to address that issue have come out strongly in its favor.  There is something to be said about having more women in powerful positions and the hope is having these reservations will address many of the social injustices faced by women. Other countries like Pakistan and Bangladesh already have reservations for women in the parliament, while the US & the UK have a much lower percentage of women legislators than Pakistan and yet have a much better social standing for women. India has had 33% reservation for women in Panchayats for over a decade and that has definitely led to an increase in women participation in politics at the grassroots level. But has that really made any difference to the social status for women, such providing access to education, improving health of women, reducing domestic violence, or has it just been touted as a panacea for all evils just because it provides the political parties with a reliable bank of votes?

Clearly, diversity is a good thing and we definitely want to encourage participation from all classes of society. Diversity provides many socio-economic benefits by bringing together people from various backgrounds, cultures and opinions. This fosters a deeper understanding of issues which may result in more appropriate solutions to address the present social and cultural problems. It also provides a platform for underprivileged classes to raise their standing in the society. In order to increase diversity, India has adopted the reservation system which allocates some percentage of the seats to minorities and women in education and public services. Other countries, such as the US, have policies of affirmative action that provide women and minorities the access to better education and have had reasonable success in improving the social standing of women and minorities alike. Does the Indian system do the same?

In my opinion, reservations cause a more divisive society rather than an integrated one. More often than not, reservations lead to a selection of poorly qualified candidates due to a persistent lack of qualified candidates. Moreover, it denies jobs and education opportunities to better qualified individuals and completely undermines the importance of merit or talent. This results in general discontent amongst the populace as they look down upon people whom reservation favors. The policy also produces an unintended counter-effect – it further deepens division along lines of gender, religion and caste and makes the society more intolerant to the needs of others. Are there better approaches that we can take to ensure diversity while still integrating the society?

To prove my point, let us look at an example from technology jobs in the US. Traditionally, high-tech industry has been a bastion of male dominance with only around 10-20% employees in this sector being women. While many technology companies like Microsoft actively pursue diversity, reservation is not one of the tools they use. Could a company like Microsoft increase the number of women by just proposing a 33% reservation of jobs on women?  This policy would be disastrous for the company. Firstly, the lack of qualified female candidates in the field will leave a large number of jobs open and it will deny jobs to a number of qualified male candidates. That would imply that either Microsoft will have to live with a smaller workforce or reduce the quality of employees, neither of which is a viable option from a business standpoint. Nor would this policy increase the number of qualified women in the sector in the future. The number of opportunities in the technology field for qualified women are limitless even without reservations, and yet this has not caused more women to join the workforce. The problems are more deep-rooted than just a lack of opportunities and we need to look at other ways of solving the issue.

The lack of women in computer jobs stems from the small number of women from computer science education. A few years ago, CMU undertook a research project which increased the percentage of female students in computer science undergraduate studies from 8% to 40% in a period of five years. This was done not by reserving seats, favoring women or diluting the candidate pool and in fact the quality of students (based on SAT scores) remained the constant throughout the study. Instead, the study attacked the social bias which caused this discrepancy. The solutions involved broadening the culture and curriculum of the department, providing a peer support group and mentorship for women and addressing the perception of the field in younger girls with the help of their teachers. This goes to show that we can considerably improve the representation of women or minorities by addressing the underlying social causes without compromising on equality. Another fine example of this approach is the preparatory program for scheduled caste students at the IITs in India. Programs such as this helps minority students prepare for further education and provide them the resources to compete with the rest of the society on an equal footing.

The same principles can be applied to women’s liberation and uplifting of the backward castes in India. Though, replicating such social programs to empower and educate women or minorities would require a significant amount of political capital and initiative and they may prove to be difficult or even impossible to implement on a wide scale in a diverse nation as India. Moreover, reservations are deeply entrenched in the present Indian psyche and they seem to provide an easy answer to the problem. But are they the right approach for the society longer term?

The Indian healthcare system is nothing to write home about, in fact it is dismal at best. The amount of government spending on healthcare is minimal, the health of the people is poorer and millions of people do not have access to decent healthcare. This is definitely not a model we want to emulate. But, there is one factor in its favor – viz. low cost. India has good medical facilities, well trained doctors and the  all the same medical treatments that are available in the US. Yet, all of this is available at a fraction of the cost of similar treatments in the US. This has resulted in a huge boom in the medical tourism industry. Before we speculate on the reasons as to why healthcare is more affordable in India, let us look at an example that illustrates the difference in cost:

A few days ago I visited a dentist in Pune. The dentist’s “office” was a tiny two room shack in the parking lot of an apartment building. In outer room or the lobby, there was no receptionist, instead there were just a few scattered chairs and benches for waiting patients to sit. We didn’t have an appointment, and the dentist probably didn’t take any. There were a few people waiting there before us, and the only way for us to figure out our turn was to wait until all those people had seen the dentist. Similarly, people who came in after us had to wait till we had had our turn. It was like an implicit queue was created by each person knowing who is before them.

We got to see the dentist after about a 30 minutes wait. The complaint was that a dental bridge had fallen out and needed to be reattached. The whole procedure took approximately 10 minutes. In fact, there were some complications, the tooth which supported the bridge was damaged and a permanent fix would have involved removing or fixing that tooth and then making a new bridge to fit in correctly. But both the dentist and the patient were satisfied with the temporary fix. A strange thing was that the dentist didn’t even know the patient’s name or have any of their records before treating them – she only asked for the name at the time of payment. This whole procedure took us about 45 minutes and set us back $6 (Rs. 300).

Now, let’s compare this to a hypothetical scenario had this same situation happened in the US. Firstly, we can’t just pop in to a dentist’s office, so we call them and ask for an appointment. We get there 10 minutes before our appointment and fill out paperwork. After waiting for 20 minutes in the lobby, the receptionist tells us that the dentist is now ready to see us. She takes us to an in-patient room and asks us to wait there. A nurse comes by to ask us the reason for our visit. She takes copious notes on our complaint and lets us know that the dentist will be in shortly. After another 15 minutes of waiting, the dentist comes by to have a look. She indicates that the support tooth is damaged and this bridge cannot be installed right now. We would need to fill the last tooth and make a new bridge. Oh well, we say – whatever. We get some X-rays done for the damaged tooth and are called back the following day. The next appointment is an hour long where the dentist works on filling the damaged tooth, after which the nurse takes some measurements for the new bridge. We are called again in a couple of days for fitting. Two days later, the bridge is ready to be installed and then we spend another hour to get it to fitted properly. This whole procedure sets us back around ~$1000. Now that’s more than a 150x cost as compared to the same treatment in India!

An obvious fallacy in this example is that the treatments given are vastly different in India vs the US. Now I’ve tried to present a realistic (albeit exaggerated) account of what would happen if a patient with a similar complaint went to a dentist in the US. Let us say that a dentist did actually provide the exact same treatment as was given India (this is unlikely in practice since the dentist needs to limit her liability) it would have still cost us ~$200 (30x of the cost in India) .

Another valid line of reasoning could conclude that the dentist in India does not get adequate monetary compensation. But that reasoning doesn’t hold up to further scrutiny. The dentist was able to see around 6 patients an hour and if we make the assumption that her rates are similar for all patients, conservatively she makes Rs 1500/hr on an average. Her clinic was open for about 4 hours a day (4pm – 8pm), so she would make Rs 6000 daily – which results in an annual revenue of Rs 1.5 million ($30,000) only for half a days worth of work. Assuming she does something else for the rest of the day, like be attached to a hospital or run the clinic in other times of the day, my guess is that her annual net income would be to the tune of Rs. 2 million (after accounting for rent, equipment and paying staff etc).  That is a fairly large income in India. To put the numbers in perspective – a starting programmer earns $70k in the US while a dentist earns $140k. In India, a starting programmer would earn Rs 0.5 million. Using that as a base, the Indian dentist is earning twice as much as her US counterpart  while keeping her costs 4x lower (after adjusting for the lower cost of living). Another point that we’ve to note that she is a dentist with a small private practice. Similarly, there would be larger more expensive dentists who would earn a lot more than her.

So why are costs lower in India? To speculate, in my opinion the main reason is free market. In India, the consumer is free to go to any doctor they wish to – public hospitals, expensive private clinics or the neighborhood doctor. The consumers bear the entire cost of the treatment and so they choose the doctor based on the utility of the treatment to them. A patient who wants to be mollycoddled and has the resources will go to an expensive clinic while a person who doesn’t want the extras and is content to wait in longer lines will go to the neighborhood doctor. This competition amongst the doctors keeps the costs low as they try to attract the most number of patients that they can treat. Another reason is efficient allocation of resources, there is no multitude of nurses, receptionists, insurance companies and other middlemen which would eat a significant portion of the cost. The transaction is between a doctor and a patient and allows the doctor to keep most of the proceeds which in turn helps keep the cost low.

Contrast this to the US, where all doctors are treated equally by insurance companies. The cost does not vary by the medical provider, it varies by the procedures performed and moreover it is paid off by the insurance provider. This basically means that there is no free market competition between doctors. Yes, there is competition for patients, but that does not translate to cost savings because the patient still bears a fixed cost to the insurance provider regardless of the doctor they see and the treatment sought. This is one point which is sorely missed by the US lawmakers. They talk about competition between private insurance providers, but how would that reduce costs if their expenses to hospitals and medical providers remain constant? Have they stopped and thought about the fact that maybe having an health insurance industry itself is the reason for the escalating healthcare costs and not the solution?

(Note: The question of how we should take this free market approach and apply it to the US healthcare system would probably be a subject of a future blog post).

Swine flu or H1N1 flu was first detected in Mexico in mid-April [4]. Initially a wide number of cases and casualties were reported and there was a general cause for concern amongst visitors to Mexico. I was in Seattle at that time and one of my colleagues was in Mexico on vacation. When he came back we even quarantined him for a week from work to prevent any of us from getting infected. In less than a week the infection had however spread to the US. Many reports indicated that the flu affected healthy adults and humans did not have natural immunity to it [5]. However, within a couple of weeks it was realized that the fear was not as grave as what a was expected. Most of the symptoms were mild and most people recovered without any treatment. The number of deaths in Mexico were retracted and slashed by more than half [6].

The one thing I observed during this whole episode was that the typical American I interacted with was not too concerned about swine flu. Note that the demographic I interact with is a urban, highly-educated, working professional – so I cannot say what the reaction from a average American would be. There were definitely school closures in Seattle, and doctors and teachers were worried, but nothing amounted to outright panic. The general perception from the Indian American community was that Americans as a species, get scared very easily and the media coverage is causing an unnecessary concern. Most people were of the opinion that you would never see such kind of panic in India as Indians have seen all sorts of diseases and a simple sneeze or flu is not going to faze them. How wrong they were.

I arrived in Pune on Aug 7th. This was just a few days after India’s first death from swine flu. Since then to the time of writing the toll in Pune has climbed to be in the teens. The panic seen amongst the populace of Pune completely shocked and surprised me and it has far outstripped its counterpart in the US. If you just look at the whole episode statistically this panic doesn’t seem justified . There are far more infectious diseases in India than swine flu. Malaria and tuberculosis kill more than 1000 people in India per day [7].  On an average one person dies per day in a fatal road accident just within the city limits of Pune [8]. Yet far more people on the streets will wear H1N1 masks than helmets. When you question the same demographic that I questioned in the US (urban, highly-educated, working professionals) you can see that they are far more concerned than their US counterparts and when you ask them why, the typical response has been “oh so many people have died”.

In my experience, people in India have a callous attitudes towards safety. Many people ignore safety warnings and regularly flout seat-belt or helmet regulation. How did a society which did not care about safety suddenly become all to concerned with a disease that is typically mild and no worse than seasonal flu at best.  There are various factors which seem to have led to this – not the least of which is media hype [9]. Mass media has seen an enormous explosion in India the last decade. If you switch on the TV at any time you will find dozens of “news” channels which are broadcasting various sensational stories. This media took the swine flu hype to an unprecedented level – every single death was glamorized and multiple pages in the newspapers were devoted to articles describing these individuals and their deaths. Compare that with the first casualty in the US – I could not find any articles about the baby which died in Texas – except for mentioning that this was the first casualty. The media never dissected that case as throughly as has been done in India.

Another cause of the panic was the poor government response. Instead of trying to maintain calm and disseminating accurate information about the disease to educate people on prevention, the public officials were more interested in closing down the city [10]. And where did this whole mask meme come from anyway? The CDC advisory recommends masks for sick people to prevent the spread of the infection [11]. Whatever happened to maintaining basic hygiene and wash your hands with soap regularly – which was the advice given everywhere else [12]. And why were family doctors and private practitioners not involved in tackling the disease right from the start? All of the care was concentrated in 1-2 public hospitals. This caused tons of people to flock to these hospitals, generally overwhelmed the system and resulted in more panic. [13]. Of course the even political response in the US was not without its failings. After all, who can forget Joe Biden’s famous remark to stop traveling in planes [14]. The difference was in how people reacted. Biden was severely criticized by the media for inciting panic and resulted in an apology from the Whitehouse [15], whilst in India the officials were chastised for not containing the epidemic further by bringing the whole city to a halt.

After two weeks the panic in Pune seems to be abating – partly because of the newspapers having a holiday on Aug 15 and a few other headlines dominating the news, and partly because the there is only a small period of time in which the people can sustain this kind of panic. There is also some effect of many organizations calling for calm [16]. The media has also wizened to the effect it has had. Consequently, Bangalore which has the second highest number of swine flu cases in India is not gripped in such a panic [17]. Some cooler heads also seem to be prevailing on how how swine flu needs to be combated [18]. But this is definitely not the end of the story, there will be a lot more deaths as the number of people infected with swine flu grows and it spreads into more rural areas with limited medical facilities, and will India be prepared to handle it?

What can we glean from this panic [19], and what are the potential outcomes -

1. India is definitely ensnared by mass media and has not developed a resistance to it like elsewhere in the world. Can this be harnessed for social good? If the media similarly concentrates on road accidents will we be able to make people wear helmets, make them aware of the dangers of drunk driving, discipline more bus drivers for rash driving and most importantly make the roads a safer place for everyone with a lot fewer casualties. You already see some media quoting these statistics [20].
2. Would there be improved tracking and handling for other infectious diseases like TB and malaria? Can a government body like a CDC for India be set up. Experience has shown that simply tracking and measuring cases have led to efforts to reduce their causes. This would result in better health for everyone in India.
3. Would there be an increase in public hygiene? If the government and media gave enough advice on how to maintain hygiene to reduce the incidence of swine flu this will have a substantially beneficial effect on other infectious diseases.
4. Would the amount of government spending on public-health increase? India has very low spending on public health as a percent of GDP [21] as compared to other countries and most of this comes from private sources. Would the effort to tackle swine flu cause the government to up this spending and be able to incorporate private institutions in improving health of the general population in India?

All of the above happening it is clearly the optimistic scenario. The pessimistic scenario would be something like: People in India get jaded by the media response and the next time there is severe infectious disease will not respond adequately as required. Or even worse, the increased panic causes people hoard up on Tamiflu supplies, resulting in a rise in cost and shortage for people who actually need the medicine. Or the worst case, due to the large incidence of people taking Tamiflu because of the panic, the H1N1 virus mutates into a highly infectious strain which is resistant to Tamiflu and causes widespread deaths.

What will actually happen? Probably something in between the two extremes. But it is really hard to predict and one can only hope for the best.

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Given that I am always behind the curve on everything, this should come as no surprise.  I am not exactly what people would call an early adopter – till about 2 weeks I was carrying a 5 year old Nokia cell, which was 2 inches thick and looked more like a cordless handset, while the whole world was moving about with iPhones and G1s. So, now that the world has moved to Twitter – I better set up a blog when no one is watching.

All right, so now there is a blog, but then what? It needs posts. What am I going to write about? I am not sure yet. The topics that I have in mind are fairly broad ranged and there isn’t any unifying theme around them. Most of the essays will be about my thoughts on what is happening around me, but there might articles on technology and software thrown in the mix as well. One thing I am pretty sure this blog won’t be about is what I ate for lunch today or where I went on vacation. That probably means that the articles will be longer and will take time to write. My goal is to write 15 articles by 1 June 2010. I have the first 2-3 topics in mind, for the rest we’ll see what we get.

So watch this space, sooner or later you might see something that may pique your interest.  The first article will be forthcoming in a day or two.