Sunday, 29 March 2015

Narayana Health - A company to watch

In its website Narayana Health (NH) states it is ‘Amongst top 50 local dynamos of the world’ (

NH’s growth is phenomenal from 225 beds in 2000 in Bangalore to 7500 beds in 2014 in 29 hospitals across 17 cities. NH wants to grow to 30000 beds by 2018. NH has a project stated to be worth $2billion over 15 years in the Cayman Islands in association with an American non-profit partner for the purposes of medical tourism style of healthcare services.  (Cayman Island has a population of approximately 57000 with the financial services industry seemingly as its main economic activity and the world’s second most significant tax haven as per Wikipedia)

In percentage terms for the number of beds is 3333% growth in 14 years which is 238% growth each year.

With that kind of growth no wonder JP Morgan and Pinebridge invested $100million for a 25% stake in the company (  ). There are news reports that they are now looking to exit.

Narayana Hrudayalaya Private Limited (NHPL) is a company with a subscribed capital of Rs 3,000,000,000.00 ($48million) and a paid up capital of Rs 3,457,530.00 ($55000) according to their last balance sheet of 31/03/2014 filed with the Indian government. NHPL has ‘charge amount secured’ as charges registered in the MCA government of India website Rs 2,005,500,000.00 ($31million) to Indian financial companies. In other words it seems like NHPL has Rs 200crores of secured loans for Rs 34 lakhs worth of paid up capital. This company has many of its stakeholders’ representatives as directors.

There is also another private limited company called Narayana Hrudayalaya Surgical Hospital Private Limited (NHSHPL) with authorised capital 50,000,000.00; paid up capital of Rs 27,027,040.00; charge amount secured Rs 541,238,215.00 In other words Rs 54crores of secured loans for a paid up capital of Rs2.7crores.

Narayana Hrudayala’s quoted profit is about 8% which is decent but not probably good enough for some.  At a capex of Rs 17.5lakhs per bed their 7500 beds would result in assets of Rs 13,125,000,000 (about $211million). However, they have already stated they are trying an asset light model, where the asset belongs to someone else and Narayana Health provides operations.

The $100million private equity investment for the 25% stake of the company would put NHPL’s value at $400million. Perhaps there are other constructs/structures/vehicles that relates to these numbers quoted in the press.  However, the subscribed capital of the company is $48million. Narayana Health website in its disclaimer, terms and conditions and copyright all refers to Narayana Hrudayalaya Private Limited, so for the purposes of this write up I am assuming that they are indeed referring to NHPL. NHPL has a variety of stakeholders including private equity representatives on its board; NHSHPL has only Dr Shetty and a couple of others on the board. As an industry watcher, I am not interested in the nitty gritty of their financial architecture. I am interested in how successful they will be in the medium and longer term.

NH and Dr Devi Shetty are known for their low cost model of private healthcare, their large scale operations and mega ambition. They have not accessed the public with a share offering yet. Their models have also been criticised ( ) There is definitely something exciting happening with NH, time will tell us whether that excitement is positive. Time will tell us whether their debt will negatively affect them, or if their assets will sustain them, or a share offering will boost them. Time will also tell if their model of innovation would be successful.

Irrespective of whether one is interested in finance, healthcare, innovation, politics, off-shore investments, medical tourism or any combination of these, Narayana Health is a company to watch.


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PS: Narayana Health and its growth fascinates me and reminds me of Apollo Hospitals in its rapid growth phase. The above information is gleaned and presented from internet searches. I will be happy to correct, amend or post additional information if that was necessary.

Wednesday, 25 March 2015

The Evolution of Language and its Impact on Racism

The Evolution of Language and its Impact on Racism

Some normal innocent original words took new meanings and won’t go away. It blights us today.

A muse on the four words, Fair, Black, Dark and White
(All etymology used in this essay is from Online Etymology Dictionary )


Whenever we see injustice, someone or a group of persons negatively affected due to no fault of theirs we claim it is unfair, we then want to fight for fairness and we want a fair society.

Fair in this context means equitable and free from bias.

Let us look at the evolutions of the word ‘fair’. 

Originally the old original English meaning was ‘beautiful’ 'pleasing to sight, attractive' and similar; it also referred to good weather.  Then around the 1200 the word fair included references to 'light skinned people'. Are you beginning to see where we are going with this? The gradual slow association between pleasing to sight, attractiveness to lighter skin. Then by 1300 the word fair begins to be associated with "according with propriety; according with justice," and also refers good/auspicious and by 1400s it refers to "equitable, impartial, just, free from bias". From 1860 it refers to "comparatively good."

So the history of the word fair starts with beautiful which gets linked to light skinned persons, begins to refer also to justice and then good. 

Fair - white skin – just/unbiased – good 

That is the sequence associations of the evolution of the word fair.


Let us now look at the word dark
The online Etymology dictionary says ‘Old English deorc "dark, obscure, gloomy; sad, cheerless; sinister, wicked," from Proto-Germanic *derkaz (cognates: Old High German tarchanjan "to hide, conceal"). "Absence of light" especially at night. Another old English link was darkly which meant horrible or foul.

That is the original meaning.

It is only as late as 1670 that dark begins to refer to ignorant. By 1700s it refers to negativity and by 1775 the word is used to refer to black people.  

The sequence here is
Dark/obscure/gloomy/sinister  -  Ignorant  -  Black people (and brown people)


Original English had two meanings for the word Black. 'When used as a noun it referred to the colour Black. The online Etymology Dictionary says ‘When used as an adjective ''Old English blæc "dark," from Proto-Germanic *blakaz "burned" (cognates: Old Norse blakkr "dark," Old High German blah "black," Swedish bläck "ink," Dutch blaken "to burn"), from PIE *bhleg- "to burn, gleam, shine, flash" (cognates: Greek phlegein "to burn, scorch," Latin flagrare "to blaze, glow, burn"), from root *bhel- (1) "to shine, flash, burn;" Or bleach''. This was probably the reference to and origins of 'blacksmith' 

'The same root produced Old English blac "bright, shining, glittering, pale;" the connecting notions being, perhaps, "fire" (bright) and "burned" (dark). " Used of dark-skinned people in Old English.'

In 1300 it begins to refer to colour of sin and sorrow, by 1500 the word black began referring  to 'dark purposes and malignant' by 1500 it is also used to refer to dishonour, besmirch;  It then gets a reference to blackmail (perhaps because it burned and scorched and not a reference to colour). So we can see the links and connotations are changing and evolving from black being a reference to colour to references to negative and bad things.

The pnemonic and bubonic plague of the 1300s was at that time not called 'black death'. In the 16th century, after the 1300 to 1500 evolution of black from reference purely to colour or burn/blaze/glow/livid,  to include negative meanings, the word black was retrospectively attached to those tragic deaths.

By 1600 you have blacklists, by 1800 you have blacksheep

Black eye "discoloration around the eye from injury"  in 1600, which is obviously a description of a physical condition, morphs into  ‘Figurative sense of "injury to pride, rebuff"  by 1744. By 1880s it also means "bad reputation".

The term Blackguard from a jovial mocking reference in 1500s becomes a references to criminal classes by 1700s

By 1920s 'in the black' means a corporate loss and by 1930s references to 'black markets' are established.

Even the black widow spider has brown, red, black and yellow on its shell but gets called 'black'

The sequential evolution is from the original black which was a colour and a reference to black persons, and had very positive terms to illustrate it gradually moved over a long period of time to refer to everything bad and negative.


The Online Etymology Dictionary says
‘White means …. "whiteness, white food, white of an egg," . Also in late Old English "a highly luminous color devoid of chroma. In old English the word White also referred to  "bright, radiant; clear, fair,"  In other language derivatives it meant  "white; to shine" (cognates: Sanskrit svetah "white;" Old Church Slavonic sviteti "to shine," svetu "light;" Lithuanian šviesti "to shine," svaityti "to brighten"). '

White was also used as a surname for persons with fair hair or complexion. 
It is indeed interesting that both black and white originally referred to 'shine' but obviously referring to different colours the meanings diverge as time passes by.

It is not as though the word white is not associated with negative meanings. But whenever it is associated with a negative meaning it is in comparison with another negativity where white comes out better off.

White collar crime – is associated with a softer version of behaviour, associated with genteel persons, linked with notions of education

White trash - is not when white people behaved in a trashy manner, it is when white people were in comparable positions to black servants (in America)

White Elephant - was a gift of honour though it was one which ruined you. The ‘elephant’ (i.e. the gifted object) is obviously of a high value, the maintenance of which cannot be afforded by an economically weaker person.

White wash - is cover up negativity, bad news, bad things.

White lie - is even a lie becomes a good thing; it is seen as a thing done to ‘benefit’ others.

Original meaning
Beautiful, pleasing, attractive
Obscure, gloomy, sad, wicked, absence of light
Colour Black, dark, burned, gleam, shine, flash, blaze, glow, bright, glittery,
Also used for dark skinned people
Colour White, radiant, clear, fair, shine, brighten
One with fair hair or complexion
Original + light skinned people

Both of above +

Sorrow, sin


Malignant purpose
Dishonour, besmirch, blackmail
Blackguard (jovial reference)


Blacklists, Blackeye (as in physical description)


Black people
Blackeye (as in Injury to pride)
Blackguard (criminal class)

All of above +
‘Comparatively good’

Blackeye (as in bad reputation)
White trash
White elephant

In the black (as in financial loss)
Black market
White wash
White lie
White collar crime


Are you seeing how it works? Humans are pattern matchers. Human brain is not primarily for analysis though very capable of it. The default position is pattern matching. Here is a more recent example of pattern matching related distortion. The nazis used the swastika and now though the swastika is actually a powerful holy positive symbol used (potentially) by a billion people in other parts of the world, in the white western European-American world it is a negative symbol. We do not look at the meaning, we look at the usage and assign meaning. Our pattern matching in the western world, now fears the swastika as a nazi thing not how it actually is which is a Vedic thing.

Similarly our pattern matching is now helpless when it comes to racism, it associates black and dark with everything negative. It associates white with everything positive. We have becomes inadvertent slaves of aspects of our possibly distorted evolution of the English language. It served the purposes of white Europe in previous times.

In 1500s many European countries abolished slavery in their own countries as they were actively taking slaves from Africa. The language associations described above show a change in usage mostly in the 1500s and then it surges forward. This links clearly with the origins of the history of European involvement in the slavery of black people around that time and its growth. There seems to have been a desperate psychological need to create these new negative links on the color-people-trait theme so as to distance justify and garner support for the white Europeans who were trading black people as slaves. The links with dark colour and negativity has left a legacy which is now seemingly impossible to resolve.

Slavery itself was much older but that was not linked to colour. It was linked to debt, war, crime, punishment. We still see the effects of those kinds of linkages in human trafficking, poverty traps etc but those are linked to numericals, philosophy, economics; and not linguistic or visual based. Therefore when we think of say human trafficking we are able to look at it in an analytical mode when process, numbers becomes solutions. When we talk about racism we become pattern matches and emotion becomes a defense. 


It can be expected that anyone who uses this rationale or logic for a change of language is going to face at the least a push back and at worse a back lash. The importance of context when interpreting words or phrases is paramount. Context however is immediate to the circumstance; even historic context is shadowed by our immediate context. Our current circumstance and context is preloaded with centuries of evolution and thus the links are woven into the genetics of the evolution of language. If context is indeed everything, then the language developed for the context of the 16th 17th and 18th centuries becomes incorrect for usage in the 21st century. By using such language in the 21st century we become automatic accomplices to perpetuation of archaic practices.
It is not a simplistic matter of political correctness, it is not moral policing, it is not thought control. It is a matter of looking clearly at the evidence and its impact. Language links up with imagination and imagery then becomes etched in our mind to be called up on every occasion we pattern match (which is pretty much all the time) – these are the origin of unconscious and subconscious bias. This is the reason why often even black people taking the Implicit Association Test on race seem to be biased towards white people.

Colour needs to be disentangled from its links to bias. This will neither be easy nor quick. There are possibly many ways of doing this. Language architects can be engaged to weed out negative connotations. This need not always be people, software can enable this effort. The positive connotations of the words currently used negatively could be increased. The latter would be a better approach but understandably both approaches would be needed.

At a personal level, every reader of this article is urged to stop using at least these four words, FAIR, DARK, BLACK and WHITE for anything other that in its original meanings. Words such as black should not be used for accountancy (‘in the black’) or the various negative connotations. Black should be used only to refer to colour. Similarly with other words. Anything other than the original meanings should be subject to extraordinarily vigorous challenge and such usage be eliminated. The future generations may have a ray of hope for an impartial world (not a fairer world) if language distortions are ironed out. 

It can be done. It is not too late.


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Post Script
The links between dark/black and negative is mainly a Europe influenced phenomenon. In the parts or the world now known as India an incarnation of God was called Krishna which literally means the 'dark/black one' - Krishna is even now the God for a billion people with all its positive connotations. However, due to the power of English across the world and the history of Britain in its influence across the world even in India the same links between colour and positive or negative traits apply though not directly to Krishna (yet). Of course, that part of the world has its own linguistic history based biases persisting till today.

References and search term links

NB: While this blog site is primarily about healthcare, I have an interest in issues such as bias, race and its impact on healthcare. I hope a better understanding these issues in the broader context, helps us deal with healthcare in a better manner.

Tuesday, 17 March 2015

Choices that Indians abroad and Indian doctors make

Indians fought for their British masters in World War 1

The Indian army personnel who died in World War 1 were commemorated recently. The Indian army during that time numbered 1.5 million soldiers, nearly 1 million fought in the war. About 75000 died and about a similar number injured. 170000 animals came from India 3,700,000 tons of supplies and stores came from India that was worth about £80million. Another £146 million monetary contribution was also provided. £1 in 1917 would be about £340 today (2015) – do the math.

Here is the most fascinating aspect of this:

All the 1.5 million were volunteers. Yes you read that right volunteers.

I heard on BBC Radio that there was even a 70 year old ‘prince’ who went to meet the Viceroy so that he can go to Europe to fight in person on behalf of the empire.

According to most reports India was a relatively rich country at that time. There are some accounts that a Rupee was worth about US $10 around WW1 time. The wealth was not available to an overwhelming majority of Indian people, the wealth was available mainly and overwhelmingly to Britain. Indian people in India were treated quite badly by the British on all accounts. Yet, 1.5 million Indians and their local masters volunteered to fight and sacrifice their lives for their British rulers. Even the great Gandhi asked people to join the armed forces.

This is a remarkable achievement of the British Empire to encourage and motivate people to support them; that ability is truly amazing and deserves congratulations.

The intriguing question is why so many Indian’s volunteered to fight and die for their colonial masters? Why did they allow so many resources to be plundered?

Did the Indians feel that given a choice of their previous muslim rulers or their own local kings and princes versus the British – supporting the Empire was the better option? Did the Indians have genuine loyalty and affection towards the British? Did the Indians have an inkling that this was a long term game and playing with the British was appropriate in 1917? Or is there something in the Indian psyche that makes them support their invaders and colonisers more than their own local people (caste, local rulers’ oppressiveness, lack of local opportunities, personal greed may have all played a part)? Given the long history of these things there seems a certain naivety or gullibility or personal selfishness that becomes apparent.

Make no mistake – I am not talking here about the extraordinarily tragic stories of people who were made indentured labour, oppressed populations and other aspects of cruel history. I am only talking here about volunteers – people who had a choice and chose the colonial British.

My knowledge and analytical ability has to take a pause as I am unable to give more reasons. But, I would like to move to looking at this through a healthcare lens.

Some stats (as though stats convinced anyone!)

The population of India is 1.278 billion

The number of registered doctors in India 885233 as of 2013

India hence has less than 0.69 doctors per 1000 population

The intake into medical colleges in India as of 2013 is 41569

The number of registered doctors in UK is 267146

The UK population is 64.1 million.

This means the UK has 4.6 doctors per 1000 population

If the number of non-practising doctors are removed from the calculation then the UK  has 3.68 per 1000

If we removed the doctors who obtained their primary medical qualification outside UK then the UK would have less than 2.63 per 1000 population

The intake into medical schools in UK is 7900 per year (as of 2013)

36.8% of doctors registered in the UK are from outside UK (their primary medical qualification i.e. MBBS is from outside the UK)

The number of doctors with a primary medical qualification in India registered in UK 24995 (as of 2014)

Stats done, lets move on.

Indian doctors abroad (especially in the UK)

From conventional economics point of view doctors in India are in short supply with great demand and even in a low income situation it should be very attractive for doctors in India to remain in India; potentially and in reality often doctors in India are relative high earners.

Yet about 25000 Indian qualified doctors work in UK. About 125000 doctors of Indian origin working in the western English speaking world, with possibly tens of thousands more working in other countries (eg middle east).

It is also thought and even recognised that Indian doctors are significantly disadvantaged and possibly even discriminated when they work abroad. I have personal knowledge of UK where the statistics and the narrative certainly does not show Indian qualified doctors are equal, there is a strong feeling and growing evidence that they are discriminated against. Examination results, sanctions by the regulators, senior posts, etc all show that International Medical Graduates and Black and Minority Ethnic do not do well in the UK.

Yet, non-UK primary medical qualification holders form 36.8% of the doctors in UK of whom 25.8% are from non-European countries with 9.4% from India. No one forced them to come to UK. They are voluntarily coming to UK.

What is happening here? 

Indians (especially Indians abroad even more especially Indian doctors abroad) need to think about how they make their choices

Is discrimination the reason? Like the rest of the world, India has discrimination too, worse in some areas than others. If discrimination was the reason, why have Indian doctors working in the UK chosen to be subject to UK style discrimination than Indian style of discrimination?

Is it the ability to contribute to the health of the population? Why do Indian doctors want to contribute to the health of the British population when the need for the Indian population is much higher?

We can talk about many aspects such as opportunities, economics, corruption, ethics, etc. The point is that the evidence shows that BME population in white societies do get the wrong end of the stick. My main question is why do Indians and in the context of this writing Indian doctors choose the wrong end of the British stick (and choose not to subject themselves to the wrong end of the Indian stick)?

A lesson for India is perhaps that the Indian stick is much harsher in day to day terms and India needs to do something about that.

But for individuals, is there a different explanation? Are Indian doctors in the UK and in the rest of the western world the equivalent of the WW1 Indian volunteers? Remember the aged prince who went to the viceroy demanding he personally fight on behalf of the British empire?

There will always be mobility of labour. The mobility of labour that the western citizen generally seem to choose is one where he/she will be treated well, the western person does not seem to volunteer to work for or sacrifice his/her life for populations who treat them badly (that is why the British people left India along with their imperial government, as they did in many other countries).

The more I think about this topic the more I am convinced that there is something about seeing oneself as a winner (which is slightly different from actually being the winner), or siding with whom we think as the winners. Power is a great influencer of cultural values, especially conventional power (money and military).  Conventional power has a certain vicious attraction where even those who suffer its negative effects begin to support it. Might propagates culture and might is often very harmful.

This makes very uncomfortable reading but those of us who have chosen to leave families behind voluntarily, who have chosen to benefit an even more an already advantaged population, those of us who have chosen to submit ourselves to disadvantage and discrimination by the west, do have to wonder whether we are naïve, whether we are gullible and whether we are selfish. Indians abroad often see themselves as winners, Indians in India often see their compatriots abroad as winners.This illusion of feeling as though you are winning while losing can be addictive and almost permanently disorienting.

If we are the new era equivalents of the Indians who volunteered to fight for the British imperial masters in WW1, our development needs are so profound that it will not be a surprise if takes generations to address.  If we really want to be winners (not just seen as winners) there needs to be a different mind set where volunteering into a generally negative situation is not a trade off for personal benefits or for some vague notions of future benefits (which will mostly remain unrealised).

If we willingly subject ourselves to abuse, there will always be someone who will willingly abuse us.


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I am a doctor with a primary medical qualification from India and every word above is applicable to me.

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Tuesday, 3 March 2015

Things that we should not learn from airlines

The Event

Recently (Feb 2015) I was waiting at Stockholm to board BA781. It was scheduled to depart at 1850. The departure monitor showed a delayed expected departure time of 2010. Naturally, I was anxious and annoyed. I changed my arrangements in UK to suit a delayed arrival.

I then checked London Heathrow Terminal 5 arrival board which said the flight was on time (in contradiction to the Stockholm departure board). I then checked BA's website which also showed that the flight was on time.

Now my hopes raised slightly. Suddenly Stockholm departure board showed a new departure time reducing the delay and a little later the board at Stockholm stated that the flight will depart on time. We were allowed to board at the originally scheduled departure time without any delays.

I boarded the flight and then cancelled my changed arrangements in UK.

Once we were settled in our seats and the doors were locked the captain made an announcement.
The captain said that there was some equipment which was faulty. Replacement equipment was arriving soon by the next BA flight from London. The new equipment will be fitted in by the engineer and only then we will leave. There will be a delay expected to be around 50 minutes or so.

All these happened and the aircraft finally took off at about 1945 hours.

Of course the reasons were explained (apparently there was only one aerobridge for that kind of aircraft), BA staff were polite and courteous.

The Issues

However, the above episode means

That BA had information about the issue before asking customers to board the flight.
They withheld information from their customers before the customers boarded the flight.
The announcement on the ‘departure’ board about the flight time was wrong, deliberately wrong.
Customers were invited to board the aircraft under what seems like a false premise of a departure Customers had no say or choice in the situation, we were blissfully unaware.

I wonder if the event would have technically qualified to be counted as wrongful restraint or false imprisonment in case someone wanted to leave the aircraft or press charges.

That statement could have shocked you. But, just think about it, change the scenario away from an aircraft to another location. Just because it was air transport by private companies we are attuned to accepting many things to the point that we are no longer shocked by whatever they do. Never mind shocked, we are often not even mildly annoyed at the concept of locking you in a plane when they know it will not take off and fully accept their justification for doing so.

It also meant that I had to make yet more changes to my arrangements in UK.

At this point let me reiterate that it is not just BA, they happen to be the illustration for this blog because I personally experienced this. Every airline company does this, every airport does this, they are probably even allowed to do all these. I have already stated that the pilot and cabin crew were polite, it is not the staff behaviour that I am complaining about. It is about the underlying core attitudes which airlines do and perhaps allowed to do.

What NOT to learn

We in healthcare are asked to learn from airlines, especially scheduled airlines. In healthcare we are asked to co-create with patients. In health care we are patient centric and are asked to be even more patient centric, quite rightly.

If a doctor or nurse or other healthcare professional staff deliberately with held information from  or provided false information to patients, for the doctor's convenience or her organisations convenience that doctor, nurse or healthcare staff is at the risk of being investigated and reprimanded.

For pilots and airlines there seem to be no such issues.

Stop asking health care to learn from pilots and airlines as though it was a one-way street, especially about customer centeredness. In airlines it is often take it or leave it presented in a way that misleads you to thinking you have real choices.

In health care patient (customer) autonomy is a core value. There are numerous other fundamental values around honesty, choice, candour and others. These are at the risk of being changed so that the presentation of these values to the patient on how good  these look, feel or sound  rather than how good the values themselves are. If healthcare was persistent on this learning from commerce, we could one day convince the patients that the presentation was more important than the value being presented. We in healthcare will be lesser that day.

It is important to constantly look for what not to learn and make sure we do not learn it.


Follow me on twitter @HemadriTweets

I have already blogged on learning (or not) from airlines, they can be found by clicking the following links:
Healthcare is not similar to aviation but lessons can be learned
Scheduled airlines are safe, just like outpatient clinics
Blondes, pilots and doctors: Who should learn from whom?