Why Kerala remained cold to queries of Nobel winners Duflo and Banerjee

It has come to light that this year's Economics Nobel winner Esther Duflo was deeply disappointed with Kerala's health officials during her interaction with them in early 2017. Top officials in Kerala now return the compliment. They say that they had serious reservations about Duflo's and Banerjee's Randomised Control Trials, and also that they had wasted no time to convey the message.

Duflo, along with her husband and co-winner Abhijith Banerjee and Gita Gopinath (who was in Harvard then and had not yet been appointed IMF chief economist), were in Kerala to get specifics about the Aardram Mission, which essentially scaled up primary health centres to family health centres, and to see whether they could use their expertise to fine tune the programme.

“What was striking was, not only did they not have any answer to our questions, but they showed no real interest in even entertaining them,” Duflo said in a working paper in March 2017, a month after she returned from Kerala, apparently exasperated by the apathy of Kerala health officials.

“Whenever we asked them to spell out what they thought their policy lever was (as opposed to their aspiration), the stock answer was that they did not really have one, that the local governments and medical officers could not be forced to do anything,” she said.

No to random trials

Former additional chief secretary (health) Rajeev Sadanandan, who invited Banerjee and Duflo to Kerala and who in Duflo's paper is simply called 'top bureaucrat', said there could be other reasons why Duflo was upset. “It is not as if the officials here did not understand what she and others asked. It is just that local level planners felt that their technique was not suitable to measure the outcomes of Aardram,” Rajeev said.

In short, there were ideological differences. “And Duflo and Banerjee were told that Kerala cannot adopt their methodology to assess the outcome of Aardram. They probably would have felt bad,” the former 'top bureaucrat' said. He also had felt it a bit embarrassing to convey the message. “I had gone to MIT (Massachusetts Institute of Technology) to invite them personally,” Rajeev said.

Docs on strike

Duflo was especially peeved that Rajeev had to quickly leave the meeting to settle a raging doctors' strike. It is clear that she felt snubbed. “He handed us over to a retired professor and a retired doctor, who have been charged with designing the specifics of the policy,” she said.

Duflo saw in this a policy maker's impatience with specifics and subtly made it clear that she had no opinion of the two people the team had been left with. “Top policy makers usually have absolutely no time for figuring out the details of a policy plan, and delegate it to 'experts',” Duflo's words heavy with sarcasm.

Rajeev Sadanandan just shrugs this away. “She does not know how Kerala functions. Moreover, the people who interacted with Banerjee, Duflo and Gita Gopinath were part of the team that evolved the Aardram Mission,” he said.

Rigid and discriminatory

On their part, the Kerala team was not particularly enthused by Banerjee's and Duflo's randomised trial method. They felt it was a bit too rigid, and removed from reality. “The question was is it possible to break health into discrete activities whose effects can be segregated from related factors and studied separately,” Rajeev said.

The Randomised Control Trial was also seen as discriminatory. While doing a randomised trial, two groups are created: a control group and an intervention group.

Now, let's say that Banerjee and Duflo wanted to assess the outcome of a particular policy detail of tuberculosis treatment under the Aardram scheme. The policy prescriptors, Kerala government, felt that if a family member, too, was trained in the basic aspects of caring for a TB patient, the results would be better. Duflo's and Banerjee's job is to test the efficacy of such a policy detail.

To do this, like in the case of clinical trials, they create a control group and an intervention group. One member each from the families in only the intervention group will be given intense training in TB care. The control group families, on the other hand, will be ignored on this count.

“Such a practice, though it could be effective, will cause deep resentment in a state like Kerala. We are so alert to our rights that we will rise up in protest even if there is discrimination in the distribution of mosquito nets,” said Dr B Eqbal, a neurologist and Planning Board member.

Nurse as half-doctor

Dr Ekbal also feels that Duflo had misunderstood the Aardram Mission. She seems to be under the impression that nurses would function as quasi doctors under the mission. “They had an ideal vision of the nurse and the village officials working together to be key dispensers of health advice,” Duflo said in the paper.

And here are two questions she had asked health officials in Kerala presuming a bigger role for nurses. “Why would patients pay attention to a nurse, given that until now they have only taken doctors seriously?” “Were they really sure that if the nurse started to take blood pressure and fill prescriptions, this would give her the authority she would need to dispense advice?”

Dr Ekbal said at no stage in the planning of Aardram Mission had the planners thought of asking nurses to take over even the least important functions of doctors, leave alone filling prescriptions. “At the most they will do a preliminary assessment of the patient, and even this is usual practice. Nonetheless, we have increased the number of nurses to four in a family health centre,” Dr Ekbal said.

Lowering infant mortality is no joke

Duflo had also made fun of Rajeev Sadanandan for having made her and Banerjee sit through a power point presentation of UN's Sustainable Development Goals and Kerala's performance. “These amounted to a long, meritorious, and likely totally vacuous, wish list (30 minutes of exercise per day mandatory in all schools, awareness of obesity to be built in communities, etc.),” Duflo said.

“It is strange she called our goals vacuous when some of them included bringing down infant mortality rate to 8 from 12 and neonatal mortality from 7 to 5 by 2020,” Dr Ekbal said.