Saturday, March 24, 2012


Re-released in many major theaters and apparently running to full-houses. This is one of my favorite movies of all time.

Wednesday, March 21, 2012

The Business Of Medicine

The intention of this post is not to put a negative spin on things or propagate a conspiracy theory. Think of it as a question I'd like to think out aloud. Like many dreamers who dream of a bright future - I often dream and look forward to developments in medical science that will bring about a cure for cancer and other deadly diseases. Then I wonder about reality.

Each project in any field needs some sort of business justification. This especially applies to the medical industry. Consider a patient getting admitted in a hospital for cancer treatment. Lets assume this hypothetical patient gets admitted to a mid-range hospital (not Apollo at the high end and not Adyar Cancer Institute at the low end).  We will also assume that a person will have at least a 2-3 year supplier-customer relationship with the hospital (The hospital is in the business of selling treatment and the patient is a customer who purchases the treatment). So - over a 3 year period the hospital stands to earn a revenue of around 10 lacs (Rs, 10, 00,000 or $20,000) from the patient. It could be more but lets assume subsidized rates and also include all the consulting fees (I actually think I am underestimating the cost. In 1989 my grandfather had brain tumor and we spent 2 lacs. Applying inflation means that today's cost would be around 16 lacs).

Now let us say some pharma company found a cure for cancer. I am the hypothetical managing director of a hypothetical Hospital ABC. I get 1000 cancer patients every year. This means my ongoing revenue is Rs 10 ^ 9 every three years. I have new medical equipment and specialists in chemotherapy that costs about Rs 10^4 every 3 years which means I make a profit of Rs 9000000 every 3 years.  What does the new cure for cancer mean to me? Consider the analogy of a Petrol Bank owner finding out one day that an alternative to petrol has been invented. What would he do? The 10 Petrol Banks he owns aren't entirely worthless. They are fuel distribution centers and so he can use the place to distribute the new form of fuel. He will have to exhaust his petrol stock and pay off loans on equipment that are petrol specific. But the key thing is: will the new fuel make him more money?

Let us set aside for a moment the notion that the medical industry is out there for a noble cause and they aim to create a 100% disease free world. Our disease is what keeps them alive. Let us assume they need to meet revenue targets, pay off loans on equipment, pay their staff etc. The first challenge for the MD of the hospital is that his existing equipment that is specific to the previous treatments for cancer is almost obsolete overnight. His non-doctor staff who are specialists in using that equipment could be put to other use. but he isn't sure. The key question that is on his mind is (a) can he use his hospital to sell the new drug? and (b) Can he charge Rs 10 lac/patient or more for administering the drug?. In effect after cutting out all costs associated with old treatment and accounting for new price of the new treatment - can he make a lot of money? If the answer to (a) and (b) is 'no' - what does he do?

The question becomes interesting - if 100 hospitals in a state begin to wonder the same thing. Then 1000 hospitals  in the country begin to wonder about this. And then 100,000 hospitals across the entire world wonder about this. Will they block  the new drug? In the 90s many eye doctors who weren't in the business of Lasic surgery were saying bad things about Lasic treatment.  Would they have said that if they stood to earn a lot from Lasic? The few eye doctors who started administering Lasic had great things to say about Lasic. So lets assume the doctor community has an incentive to block the cure if it doesn't bring them good business. Add to this the constraint that WTO imposes that newly invented drugs must be discounted by 97% for developing countries - which led to the Intellectual-Property-rights-quashing historical judgement against Bayer. This doesn't provide a lot of incentive for pharma companies to develop a 'eliminate-the-disease' kind of cure. What if the Pharma companies who are supposed to be doing research and inventing a cure for cancer are also in the business of supplying drugs for existing cancer treatment? What if they don't see a good business case that supports inventing the drug?

This brings me to my question. I am sure I am missing something here and I'd like to know what that is. In my lifetime I haven't heard of a life-threatening disease being cured by a newly invented pill. I actually haven't seen the big diseases getting knocked out by medical science related improvements. Doctors pretty much give the same answers today for brain tumor as they gave in my Grandfather's case 20 years ago. I assume cure for small pox, polio, MMR etc came before medical industry became a huge business. Is the research world really as incestual as I describe it to be (That the people who research on a new drug are funded by the same organization that produces existing drugs and the new drug will cannibalize revenue from existing drug)? Would the public ever find out if legitimate cure for cancer has been kept in abeyance because people haven't found a business solution yet? How would new breakthroughs in medical science find its way to the public? Is it purely by accident or is it caused by market forces where errors in the existing system get amplified over time causing the cure to slip through the cracks and into public domain?

Friday, March 09, 2012

Rahul Dravid

Purists. The amazing thing about this breed of people is that they are neither glamorous nor have superstar status. In fact they are downright unpopular among the masses. No cricket stadium would fill-up in anticipation because Rahul Dravid is coming out to bat. In fact - most times Dravid's dismissal has been received with a thundering roar of applause. That is mostly a testament to the batsman walking in next and not so much of an indictment on the batsman walking out. Yet for a connoisseur Dravid represents a kind of exclusivity that no one else offers. Sitting on the couch and watching Dravid construct an innings by patiently leaving ball after a ball is the ultimate snob's nirvana. You will always meet a degenrate who will come and ask you 'ennada dravai(d)' (a pun on his name and tamil word for boredom). A perfect opportunity to ask the person to go dance in an independence day bhangra dance party instead.

The purest pleasure of watching test cricket is seeing dot ball after dot ball elapse as the plot thickens like an invisible noose tightening around the neck. With Dravid the noose was visible and so enthralling. If it were a Tendulkar the superhuman aura of the batsman would have made us think the noose does not matter until it snaps the neck, and a second later we'd switch off the TV. With Dravid you saw someone battle the plot, the bowler and everyother dimension of cricket. Dravid embodies all that I had heard about test cricket prior to the emergence of the television era. He has probably listened to a lot of radio commentaries, read up on the history of cricket and as a result inherently embodies that vision accurately. In a way it is sad that Dravid played in the era of TV. In a different era where batsmen lived in the minds of public because of the way radio commentators described them - Dravid would have been a colossus.

If Dravid had played in an another era unoccupied by Tendulkar, Ganguly and Laxman - he would have been recognized as a Gavaskar 2.0 who figured out how to play ODIs. In this era however, he allowed himself to be contrasted with players who were as core to the team as Dravid. Players who are very different from Dravid. He was part of an ideal combination that could not have been planned for deliberately. It was more of a happenstance, a stroke of luck. The Ganguly - Dravid relationship to me is as close to James T. Kirk and Spock as it can get in the cricketing world. Ganguly representing the human condition in full cry with all its associated emotions and failings. Dravid on the other hand was a student of cold logic. A robot, a thinker, a calculator - a methodical operator. A captain and a first officer combination that ultimate cricket fantasies are made of.

I look forward to Dravid's autobiography. I am sure he will write it himself instead of someone like Bhogle vomitting all over the book in the name of ghost writing. I am curious to know what he thought of Greg Chappell. I have a bet going on that he was more in agreement with Greg and more in disagreement with the general public. But it has to wait for another day. Dravid's captaincy and the combination with Greg had so much potential. The combustion of Indian cricket in the Greg period and traditional confusion that exists in India over ODI performance Vs Test performance - nipped in the bud - an era where Dravid could have gone on to be a ruthless effecient captain along the lines of Waugh.

I don't know which memory of Dravid, I'll cherish the most. There aren't many innings of Dravid that I've not watched. I remember his first test century in Johanessburg like yesterday. He should have made that a 'century in both innings' but at least he ended up almost setting up a test match victory (his statemates couldnt get rid of the tail). That was the first time I saw the Indian team with a realistic chance of winning a test abroad. His first ODI century in Chepauk was great for its thrilling hunt and tragic end. The 78 in Bridgetown against Ambrose and Walsh was an unspoken masterpiece. The 4 consecutive centuries were an absolute joy. His 39 against Australia in 01 Mumbai was an excellent innings cut short by Warne. I almsot cried then. After the Slater incident we had to win it. That he became Warne's bunny again was tragic. Mostly Dravid will be remembered for being emotionless enough to be perceived as a second fiddle. He represented the purest emotion which dictates that you can achieve anything if you dont mind being outside the spotlight. People needed to be reminded that he hit centuries when Ganguly and Tendulkar hit 180+ in ODIs. His exit was as un-glamorous as it comes. A quiet quick goodbye that has the 'kanden seethaiyai' type opening sentence that Kamban would have been proud of.

He exits the game when he is still the among top 2 batsman in the team with no viable replacement in sight. Gavaskar's was the last such retirement. I guess when he says he leaves the game with sadness he means not being able to win a test series in South Africa and Australia. Surely a dissapointing blot for an ambitous cricket such as he. When he says he is proud - I guess he is referring to the fact that he is the only captain after Wadekar to win an away series against WI and Eng in an identical back-to-back fashion. Or to the fact that he went where no man had gone before (this includes Lara) in that one-man-show that was the 2003 Adelaide test.

I wonder if Waugh will write the foreword of his autobiography. Because Dravid wrote the foreword of Waugh's. It had a statement that reflected Dravid's own identity: "Steve’s legacy is hard to define, but I will remember him because he gave grit a good name. He proved that it is not only the pretty player who can capture the imagination, but also the tough and determined. Suddenly these qualities became as vital, as spoken about, as silken grace and sublime timing. He was leathery tough, played the game aggressively, and would do whatever it took within the rules to win. He built a team that has achieved legendary status, raised the level of young cricketers who played under him, and also embraced the traditions of the game and highlighted their importance. His ruthless style, combined with a passion for the game, has won him a staggering, almost unrivalled, following in India".

Lastly. Ilayaraja's music is often remembered for a nuanced silence he introduces to the unsuspecting listener. Yes, that subtle silence between interludes. You may not notice it. But the song wouldn't be the same if not for those moments. Do you remember what Dravid retorted when Donald snarled at him during that magnificent innings of 83 in the ODI tri-series finals? You don't. Because it doesn't exist. I don't think Dravid played a better ODI innings than that one. Dravid will be remembered for the strokes he refused to play, the words he refused to say and the actions he did not do. You might've missed those moments of silence. But without it Dravid's magnum opus career would have looked less elegant. And from walking away on his own after feathering that Chris Lewis ball at Lords to his retirement speech. Dravid was all elegance.