The economics of congestion

This is a piece by Sunita Narain, Center for Science and Environment.


Five costs have to be added to the price of each vehicle.
One, the cost of building a road.
Two, the cost of maintaining roads, the cost of policing on the road, the cost of powering the millions of traffic lights.
Three, the crippling cost of local air pollution and bad health which requires
monitoring, control and regulation. Added to this, is evidence that vehicles are key contributors to pollution, which is feeding climate change and will result in even bigger costs.
Four, the cost of congestion, which every motorist on a busy road imposes on fellow travellers - from delays that cost time, to increased fuel consumption that costs money.
Five, the cost of space for parking vehicles, at home
and at work.

We need to ask why economists - the ones who normally rant about markets, the need for full cost pricing and removal of subsidies - never account for these costs in their calculations of growth. After all,the cold logic of the market, repeatedly cited when it comes to the meagre support given to farmers,should apply here as well. Could it be that our economists are so vertically integrated to the market - with mind and matter - that these distortions fail to catch their attention?

Take roads. We know that cars on roads are like the proverbial cup that always fills up. Cities invest in roads, but fight the losing battle of the bulge:congestion. The US provides up to four times more road space per capita than most European cities, and up to eight times more road space per capita as compared to the crowded cities of Asia. When more roads fail to solve the problem, governments invest in flyovers and elevated highways. These roads occupy space - real estate - and are costly to build and maintain. It has been estimated that in Western cities dependent on automobiles, it could cost as much as us $260 per capita per year to operate these facilities.

But this investment is also not paying off as ever increasing cars fill the ever increasing space. This is why experts say building roads to fit cars is like trying to put out a fire with petrol. Britain's orbital motorway, something akin to Delhi's Ring Road that 'bypasses' the city, was built 20 years ago. Since then, it has been expanded at huge costs to 12 lanes. But bumper-to-bumper traffic on it has dubbed it the nation's biggest car park.

Congestion costs the earth, in terms of lost hours spent in traffic; in terms of fuel and in terms of pollution. In the us, the congestion bill for 85 cities totalled to a staggering us $63 billion in 2003. This calculated only the cost of hours lost - some 3.7 billion - and extra fuel consumed, not the loss of opportunity because of missed meetings and other such factors. In the UK, the industry has pegged the figure at us $30 billion. Our part of the world is similarly blessed: Bangkok estimates that it loses 6 per cent of its economic production due to traffic congestion. These costs do not even begin to account for pollution: emissions of hydrocarbons and carbon monoxide are linked with speed and frequent stop and start.

The logic of the market tells us that people overuse goods and services that come free. Why, then, should this dictum not be applied to roads? Why should fiscal policy not be designed to reflect the real cost of this public asset? Why not charge for it?

The question of who should pay is simple: the user. But what is often not understood is the nature - colour and class - of the 'real' user of the public largess in our economies. While in the Western world, the car has replaced the bus or bicycle, in our world it has only marginalised its space. Therefore, even in a rich city like Delhi, cars and two-wheelers carry less than 20 per cent of the city's commuting passengers. The rest are transported by buses, bicycles or other means. But the operational fact is that these cars and two-wheelers occupy over 90 percent of the city's road space. Therefore, it is evident that the user of the public space and the
beneficiary of public largess - the road, the flyover or the elevated highway - is the person in the car or the two-wheeler.

Cars do not only cost on the road. They also cost when they are parked. Personal vehicles stay parked roughly 90 per cent of the time; the land they occupy costs real estate. Cars occupy more space for parking than what we need to work in our office:
23 sq metres to park a car, against 15 sq metres to park a desk. My colleagues have estimated that the one million-odd cars in Delhi would take up roughly 11 per cent of the city's urban area. Green spaces in the city take up roughly the same.

Ultimately, the issue is not even what it costs. The issue is why we are not computing the costs or
estimating its losses.

Clinical Practice or Research

Last week's issue of the Lancet carries a profile of Dr Michel Kazatchkine, the president of the GFATM.It starts thus:

"In 1983, Michel Kazatchkine was a clinical immunologist at the Hôpital Broussais in Paris, France, when he was called to see a French couple with unexplained fever and severe immune deficiency who had been airlifted home from Africa. This man and woman were the first of many AIDS patients that Kazatchkine would take care of in the coming decades. There were no effective antiretroviral treatments available, and the couple lived only a few months on the ward before dying. “Those were difficult years with patients dying every day on the wards”, Kazatchkine recalls. Much of his time, he says, was spent providing end-of-life care, consoling patients, “and holding their hands when they were dying”."..............

And goes on about his early days. Dr Kazatchkine says he wanted to do something in hematology or nephrology while in medical school as "those were the fields you could really work on to study the pathogenesis of disease"

No comparisons really but thats quite the thought that occurred to me while I mulled between an interesting but not so lucrative endocrinology and ...what everyone told me to take- obscenely loaded cardiology.

It is sad I almost developed an abhorrence to surgery after I finished my postings at the department of surgery at BJ. Its the people who make an institute...and after getting a taste of the megalomaniacs at SGH, I told myself- "I dont want to be like these guys"
That premise was flawed, I realize in retrospect, as I was confusing my dislike to the people whom I saw practicing the subject with my feelings to the subject itself. I didn't want to make that mistake while choosing my subject of specialisation as I did love cardiology, but whatever practice of cardiology I have seen thus far makes me distraught and feel hopeless....and it was not very different this time last year when I was on the hot seat of my career.I am glad I have passed that crossroad unscathed, without regrets at being a fence sitter. I seemed to like most subspecialities of medicine. Not my fault really.But you can really practice a subject just the way you like to if you know what you want of it.You dont have to fit in moulds.Thats need based practice. Its sad that this can work to either good ( Paul Farmer) or bad( Ruby Hall Clinic) effect.

As long as I can do what I want to do, I think every subject has its utility/ charm. It is sad that some fields are not as monetarily rewarding as others.

My logic: If I can do what I want to do , and yet have the money for an occasional indulgence, and be able to pay for a comfortable life to someone who may choose to be dependent on me- I can do that only in what way I am choosing to follow now.

Coming to the original point: The Dr Kazatchkine thing.Bench work research or clinical work? ( I tend to drift off,na?...but then I think of it this way- Cardio= Clinical practice; Endo/hem onc = research )

Its disheartening to have this dichotomy. Why not both?

Bench work research( non existent in the place I might have ended up in) means knowing the guinea pig chordae tendinae and where to inject the ASOs to EF2 in its left main artery better than recognizing post wall MIs in a clinical case.The best chapters in Harrison are the ones in Endo, hem/onc. The Nobel prize in health related fields is awarded not in medicine but in physiology. Harrison 16th seems more and more like a book of pathophysiology than clinical practice. I used to think OTM was more clinical. But I guess, the Brits realized that if you cant beat the yanks, join em!Thats the way the world is going.We owe this to Drs Khurana and Fred Sanger and to the countless people who sit hunched over their elbows in labs, with the temerity to ask "Why", the ingenuity to frame a hypothesis, and the industry to put it to test in real time.Where will they find the time to see a patient. They have but one life , with just 24 hrs to the day.


Clinical work only is like the mayhem at KEM - overwhelmingly fantastic variety of cases but no audit! If only we showed the world what we manage!!It is also what one would refer to as , variously in other forms, private practice, GP giri,MOship. Not really bad.....but, .........

where's the music.

Some of the best clinicians in the world probably died/retired from practice from Govt medical colleges in Chennai, Solapur and Pune.They could pick a CP from a distance or a CTGV from history alone. They could manage complicated rheum cases with whatever little armamentarium they had to diagnose and treat, but they never kept note of how many they were treating, what were the parameters, what were the determinants of outcome.Even people in Mumbai( a certain Dr Medhekar) didn't know of their abilities( "lousy village docs...they prescribe, Sai baba treats")...how would the world ever know.

If I wanted to do both research work and good clinical practice....and risk not being a nut entirely.


" How do you know what you are going to do, until you actually do it"
---- Holden, in Catcher in the Rye

Dr 90210

You would probably think the ad pasted along side is for maybe Starbucks/ Dunkin Donuts or some other drink -maybe of the fancy sort Ivan Lendl used to chew on( always used to wonder what he had in that cup)But the cup reads toronto plastic surgery!Haven t figured out how the ad represents achievements in plastic surgery.Does the lady in the picture have teeth like Ugly Betty or a cleft lip? Maybe thats the idea. But there should have been an image that reveals that. But then that wouldn't have been cosmetic right?
I was always under the impression that people do not prefer to take up plastic surgery as a specialty.My friend Shaunak was perhaps the first person I met who wanted to take plastic surgery by choice. And he joins at Baroda this week.And then from inquiries I realise that cosmetic plastic surgery is a big bucks business!
I was surprised to hear that young Gujarati girls are a big clientele seeking boob jobs and nip/tucks!before they tie the knot. Botox, well- every aandu pandu chaitu paitu guy seems to be giving botox to rich uneducated party hopping sindhi/ bawi females for crows' feet,age lines and even to create that sexy droopy look!There was an article in the PT today about an international plastic surgery conference to be held in Pune in November. Among those attending include the guy who did the first face transplant in the world, one person who pioneered a technique to increase the girth and length of the penis! and in what seems almost antediluvian for all the bra burning, cigarette toting combative feminist summits we seem to have reached , a procedure called revirgination!!!
I pause to think. Why do these guys do this? I mean why do they even exist? It is because they do have a clientèle. A rich,affording group mind you. With lots of money in their pockets one would imagine that they are also educated.At least logical in thought process and reasoning - to have made all that money. Then why do they choose so?
Like infertility specialists, I believe these guys are not needed on the planet at all.But again thats my opinion. And I dont have that filthy kind of money either.Makes me wonder whether we can call the profession pious at all- since we are just delivering a service- a membrane, an Oedipal phallus, a perfectly shaped, teated dome of saline that should spill out just enough to titillate and crease less faces like a perfectly ironed sari or pant. We expect a good service when we stitch a pant or get a haircut or do some raffu work, - we are not expected to respect the karigar or the nai or the darzi the way we expect our patients to salaam-thokofy us while we smile goofily back as if we are know all Oracles.

There was an interesting story I had read about when I was doing my residency at KEM. An unclaimed female body was found on a sunday morning at Tilak bridge near Dadar. At autopsy the pathologist was surprised to find saline breast implants in the body. No one claimed the body of course.
And guess which paper carried this story: Mid-Day of course, right beside mid day mate.

Just a thought!

If this movie were to be remade in current day, I wonder if it would do as well as a Rang de Basanti.

Disawoval

This is a counterpoint to the earlier post. Copied, edited and pasted from an original with no disrespect to the same, but to context.Not entirely point-counterpoint, but appeals to the verse, rhyme, music searching intuitiveness.

“THOSE WHOM THE GODS LOVE DIE YOUNG"

No one can look without a touch of sorrow upon a work that death has intercepted. Stand in an orchard when the spring gales roughly fling the blossoms and the unformed fruit to shrivel on the grass. Or see that withered nosegay in the dusty road on which the evening vainly drops its quickening dew: why should a few wild roses, buttercups and poppies make one feel that being picked they would not have been thus left to die except for rue? Or read the half-told tale until you come to where the writer had to lay down the pen for ever. In a word, go when you will where death steps in to put an unexpected full stop in the sentence of a life. It seems indeed that, as Lord Tennyson said, our only teachers are time and God:
"The best is yet to be
The last of life, for which the first was made.
Our times are in his hand
Who saith, 'a whole I planned,
Youth shows but half, trust God, see all, nor be afraid."

And yet, how few who have not known days when they wished they had died in youth, died when the whole world was small compared with their boundless hope, died when the sun and stars, and the hills and the flowers, and wide, wide sea still shimmered in gleaming brightness through an unrent veil of mist, died when faith still taught that this wicked world is good, died when ambition glowed with such fervour that no effort seemed great enough, died before time had revealed that a mother, a father, a brother, a sister, a friend may be unkind, before death had wrung the heart dry of all comfort except one promise that Someone is the life, died, as Stevenson says, "in the hot-fit of life, a tip-toe on the highest point of being," whence one could pass "at a bound to the other side, the noise of the mallet and chisel scarcely quenched and the trumpets hardly done blowing."

The value of life cannot be measured by its length; a few years may leave an indelible trace on the world; much joy and sorrow may be crowded into a short intense existence-such for instance as Pompilia's, Shelley's, Ganymede's. And readers of Goethe cannot hear this last name without thinking of the upward longing, up and upward thither where young minds so easily, so fondly dwell,--where hearts can be that wish for room to love, where artist souls may linger when they dream of beauty that eludes them, where music seems to come uncalled to give expression to the tenderest emotions.

And with the bereaved one may indeed ask "why before then?" Why should we hear a mourner by a child's death-bed sobbing, "Is it good that a child should die? Is it good that the light should turn dark, the dawn die in east? Is it good that the frail fair spring should shrivel in an April frost that the blossoms and blooms should wither before summer's coming? Is it right that lambs should languish, that the birds should find closed beaks when they fly to their nests with food? Is it good a child should die, die in its lovely innocence, in its joy, in its hope, in its love? Why should death steal a life full of promise, full of unknown possibilities? Is it good? Is it good? Yet they say that the children that
die are the ones whom the gods love most!"

Few utterances are sadder than Marcus Aurelius’ words, "As autumn leaves thy little ones!" But surely that beautiful thought "to the not yet realized" betrays the golden malleable heart hidden by that steely will. There is the whole secret of that confident assertion that those whom the gods love die young. It is because there is somewhere deep down in the innermost recesses of every human heart the conviction that it is not to nothingness but to the "not yet realized" that we go when we leave this world.


But after all there comes, like half-obliterated memories fetched back to mind in later years, the knowledge that no death is premature. How can it be? We ask not for the privilege of living. What if it comes during the first young years? God calls a loved child; can we wonder that the child we love so deeply is one of those whom God loves too, so that He cannot spare him any longer? And in our most despondent moments we may hear, like some old melody that takes the mind back to loved scenes long since lost, the sweet words:--
"I know not where His islands lift
Their fronded palms in air;
I only know I cannot drift
Beyond His love and care."

-----not my words--------------------------------------------------------------------

Those whom God loves, die young

When I give up the helm

I know that the time has come for thee to take it.

What there is to do will be instantly done.

Vain is this struggle.

Then take away your hands

and silently put up with your defeat, my heart,

and think it your good fortune to sit perfectly still

where you are placed.

These my lamps are blown out at every little puff of wind,

and trying to light them I forget all else again and again.

But I shall be wise this time and wait in the dark,

spreading my mat on the floor;

and whenever it is thy pleasure, my lord,

come silently and take thy seat here.

-Rabindranath Tagore, Gitanjali

I am just your average Joe kind of guy who is probably good at test taking

The more I look at my CV, the more I seem to think so.

Have followed a more or less linear path- exam after exam after exam. 10/12/MBBS/MD.Was nearly heading into a DM reversal of role.That was aborted by something I still have two thoughts about.
But really cant escape the lack of laterality in what I have done/ achieved thus far.It seems someone has already done the spadework, thought and written the books we read, made the algorithms,defined the parameters, set the rates for 'cut', devised the techniques, attended the conferences, constructed the hospitals,established the contacts,conceptualized ethic and ethics.
And you just drift inertly from one to another. Go through the same motions in a quest to learn more and more about less and less.

DRK asked me " besides your score, what have you in your CV?"
I went openmouthedexpressionlesslimpideyes " blink, blink"

Probably I could commiserate thinking that ( as Dents says) "today is the first day of the rest of my life" and ( as Gaurav says) "age is just a state of mind"

So maybe I could pretend not to feel old or mediocre when students call me " Sir"

Thats a good start.

Night ICU!!

केव्हा तरी पहाटे, उलटून रात गेली
मिटले चुकून डोळे, हरवून रात गेली

सांगू तरी कसे मी, वय कोवळे उन्हाचे
उसवून श्वास माझा, फसवून रात गेली

कळले मला न केव्हा, सुटली मिठी जराशी
कळले मला न केव्हा, निसटून रात गेली

उरले उरात काही, आवाज चांदण्यांचे
आकाश तारकांचे, उचलून रात गेली

स्मरल्या मला न तेव्हा, माझ्याच गीत पंक्ती
मग ओळ शेवटाची, सुचवून रात गेली

So long...and thanks for all the Babel fish!

Peregrination again! Again the whole rigmarole of black suit, portfolio bags and smiling nothings played in front of an audience of conscience, pride,introspection and Program Directors.Of comforting existentialist questions into hush-hush-later decrepit corners, of wasted trash bags- what a paradox; cheap gas-huge cars; Italian Irish prissiness-kallu ghettoes,of looking away from poverty by looking into your huge American car; pan discontentment becoming a friend for fear of becoming banal, shooting career and cortisol into dizzy Megarathean heights; of neuroticism begetting loneliness and loneliness begetting neuroticism- the land abounds in Sertraline which can be picked by the alleyways of Yourphysician boroughs in big apples and boughs in sunshine cities; of reading newspapers on ...online,of toilet paper abrasions, ....of a perpetual yearning- for what one forgets, as newer sensory experiences continue to opiate your mind into an amnesic dysphasic state.Perhaps that yearning is what keeps you going when 5ht and love abandon you. You keep evolving( thats positive) into neo-citizens of a migrant hitchhiker clan with no where to go and yet the entire world in front of you .

Anyways - times for decisions are tough times. They are when all your refinement seems to abandon you and you think like a seventh grader being taught matrices; despite all the logical reasoning that seems so good in theory putting the variables into sides of an equation or forming a Null hypothesis seems abstruse.Especially when one-way roads lead to different points of no return.And these points cannot be imagined for we have never seen them...we have to create these points of reference.This is where a bad experience of past comes handy.This is where integrity of thought, faith( in God maybe,in self mostly)and other such kitschy sounding qualities might help us out.


The ultimate question in life is not exactly framed.It goes pretentiously something like( in Quasi Mode): "what is the meaning of life, universe and all such things" ....Notice the lack of a question mark after that question- for it is an infinite quantity...you have to draw a vector from point("wh..) to point (..gs") and accelerate it at 9.8 times the speed of light within limits zero to infinity using Leibnitzian integrity of thought....and hope to reach the bigQ.

The answer thought is 42.

The question was to be framed by a big supercomputer that computed at a rate that was a quadrillion times faster than the best computer ever built.Somebody called this computer the earth.Unfortunately, just hours before the 6 million or so years time limit it took for the earth to compute the ultimate question, it was destroyed by Vogons.

Thats-- so....frickin....improbable!
But so are many other things.Goedel's theorem, Bertie Russel's barber paradox...usw.
All completely logical problems.

Morals and logic are windows through which we see the vast infiniteness of the probably or improbably infinite universe.They are just the implasticity of some obstinate gyrus-sulcus in the finite billion neuron populated cerebral cortex.

The rest we have to figure out....with integrity of thought, faith( in God probably, but mostly self) and other such kitschy sounding albeit very useful qualities we have.

Point A --------( mostly a billion points in between)---------> Point B
Point A: ( variously) cause, gene, big bang, birth, stimulus, thought
Point B: ( variously, but inconsistently) effect, protein,universe, rebirth?,response/tolerance,string theory .

Why was I writing happy- puppy poems while the world was smart enough and nanobiotech like hot hot things were staring me in the face

I am still thinking!