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Monday, May 6, 2019

India's healthcare system - a story over infographics

There are two kinds of people who work in public health. I think of them as the “Market-Facing Types” and the “System-Lens Types”. The first kind believes that answers to the toughest global health challenges will only be found through market-based solutions. Solutions that include strategic pricing, supply-chain efficiencies, increased access to bottom of pyramid (BoP) markets, economies of scale and profitable private investments. The second lot believes that responsibility for healthcare provision lies squarely with elected governments and public systems, which admittedly are flawed and fragile; building and strengthening these systems is the only long-term, patient-centric and just solution to healthcare challenges. In the long-term, we’ll probably find that the two perspectives need to co-exist, work together and hold each other accountable, but for now, as in other conflicts, each side shakes its head at the other, calling it “na├»ve”, “narrow”, etc. 

Eight years ago, I started my career in public health bang in the middle of the market-facing lot and was, for the longest time, unable to see beyond that particular point of view. I’ve found myself creeping towards the middle recently though. Maybe it comes from spending time with friends who work in places where markets seem like distant realities, places where people live with zero access to formal healthcare, places where an easily treatable illness can easily be the cause of death and debt. 

I began 2019 with a goal to better understand healthcare systems. I have an excellent learning ground too – I live in India, home to the largest pool of healthcare needs, and perhaps the most complex health infrastructure in the world. In this article, I plan to summarise my big picture understanding of India’s healthcare system, under four heads:
  1. What are the major events in India’s healthcare system evolution? 
  2. What does the healthcare infrastructure in the country look like? As in, how is the healthcare delivered?
  3. What are the governance mechanisms? In other words, where will the innovation and change come from?
  4. What are the big healthcare issues to think about? 
Here goes, #1: Evolution and timeline:
Infographic #1: Timeline


These are only the events that interest me the most, so I admit there are some important ones that I’m missing out. My work has been primarily in infectious diseases, specifically TB and HIV, so events relevant to these are what jump out at me. It is absolutely fascinating to me - 
  • that a report submitted in 1946 continues to be the basis of not only current health structures, but also ongoing policy discussions,
  • that we started to talk about the need to engage with the private sector only in 2002,
  • that 19 years after the government launched the pulse polio program, India was officially declared polio-free. This gives me hope for TB eradication. But not too much - the plan was to eliminate kala-azar and filariasis by 2017 and leprosy by 2018 (spoiler alert: we didn't) 
Part 2: What does the healthcare infrastructure in the country look like?
Part 3: What are the governance mechanisms in healthcare? Who does what?
Part 4: What are the biggest issues in healthcare?


Tuesday, April 30, 2019

The Terror of the Bridge Course


“Bridge Courses” for care providers continue to sit squarely on the divisive lines among Indian healthcare experts. One side sees it as the path-breaking innovation that access denied communities desperately need, the glue that will fix our broken healthcare system, the one ring to bind us all in a smooth patient care pathway of quality primary care, efficient referral networks and focused secondary and tertiary care systems. The other side, equally passionate, is convinced that it will lead to large-scale malpractice, patient mismanagement and exploitation. I’m interested in examining this burning issue, and there are three questions I’d like to explore: 
  1. What is a bridge course, and why does the government of India keep proposing it?
  2. Why do my doctor friends dislike it so much?
  3. Could there be redemption for this “innovation” after all?
What is a bridge course?
Everyone knows this, but let’s say it again anyway – India has a shortage of qualified doctors. Bridge courses have often been mentioned among GOI's approaches to address the issue. In early 2017, the national medical council (NMC) proposed to build a mid-level cadre of healthcare workers by providing a six-month long “bridge course” to a variety of non-MBBS personnel who are part of India’s healthcare universe: AYUSH providers, nursing cadres, pharmacists and others, including informal providers (some state governments call such informal providers UMPs or unregistered medical practitioners, a far better term than “quacks”, which brings in unnecessary derision and makes the debate shallow). Post-training, these “bridged course trained providers” - let’s call them BPs - would be given conditional licenses to provide primary care and referral services in underserved areas. Anecdotal evidence indicates that a large proportion of the country's healthcare - primary care as well as emergency services - is already managed by UMPs. Bridge courses have the potential to make the system formal, accountable and transparent. 


Why is the formal medical community so repulsed by the bridge course? 
About 5 minutes after the NMC submitted the bill to parliament,  Indian medical association (IMA) and other physician groups erupted in passionate protests to get the bridge course proposal scrapped. Their key argument was that patient care will deteriorate under a system where healthcare delivery is provided by non-MBBS personnel. How can someone trained over six-months provide care comparable to an MBBS doctor with five plus years of training? My knee jerk response was that less-than-perfect-care ought to be better than the no-care which is the current state of affairs in areas where BPs would serve, but I dug deeper to better understand my doctor friends’ reasons for resistance:
  • It will be an implementation nightmare: It will be nearly impossible to ensure training quality, the UMPs will provide low quality care, keep managing cases beyond their skill set, either not refer patients to qualified secondary care at all, or only refer them when it is too late. 
  • The UMPs will encroach on the qualified doctors’ work: Even though BPs are meant to provide services in underserved rural and urban areas, financial incentives might drive them to migrate to overcrowded urban areas. Hospitals, whose profits are under pressure now more than ever, may to prefer to save costs by hiring these providers rather than formal medical doctors. Urban patients, who have the tendency to "doctor-shop", may prefer to walk in into clinics run by these BPs for cheaper care.
  • These courses are a threat and disrespect to the medical profession: BPs may indeed solve some of the doctor shortage issue, but this may reduce government inclination to build new medical colleges or to improve the medical education infrastructure. Also, if such ‘short-cuts’ to education are available, why would young people invest their decades of their lives in pursuing medical education? As my articulate friend Dr. Sonal Verma puts it - "I favor fixing our broken roads rather than building yet another weak bridge". 

It would be simplistic to dismiss some of these issues as being doctor-centric rather than patient-centric. Healthcare system strengthening plans need to be firmly entrenched within these realities of the medical profession in India. The protests worked, and bridge courses were removed from the NMC bill in 2018. GOI instructed states to take their own decisions on training programs for lay providers. IMA seems to have won the battle, but war is far from over, and it might be premature to throw the idea into the “absolutely irrelevant” pile just yet. Ministry of Health and Family Welfare (MOHFW) has now (in April 2019) proposed a bridge course to train dentists to practice as MBBS physicians. This has led to a fresh round of protests.


Is there room for redemption?
Bridge courses might be inspired by what WHO calls “task shifting” - a process of delegation where appropriate tasks are moved from highly specialized to less specialized health workers. Task shifting has been implemented widely to address care delivery gaps in multiple areas, from HIV care to cardiovascular triage. Although recognized as a method to increase efficiency in healthcare, success rates vary across case studies and depend on a lot of related factors. Here’s my list, admittedly far from complete, of elements that need to be brought in before bridge courses become a part of India’s healthcare system:
  • Stringently developed, expertly delivered course content, with local customization as necessary 
  • Accountability not only in course content delivery but also in service delivery
  • Transparent referral networks based on digital tools that work
  • Incentive structures rooted in local social and cultural realities 
  • Advocacy and behavior change (​of all stakeholders including doctors, patients, other healthcare providers as well as communities) driven by evidence rather than rhetoric

Whether these bridges get built or burnt down will remain uncertain for now given the political landscape. It is important to note that the bridge course debate is central to the issue of healthcare access in India, and is relevant to other key questions: Is increasing the number of seats in medical colleges an efficient solution to doctor shortage? As more and more physicians prefer to get trained in specialized fields and immigrate to practice in the developed world or in tier 1 cities, who's responsible for primary care, especially in small towns and rural areas?



Given the limited evidence, the debate continues to be based on conjecture and expert opinion. Operational research, perhaps at subnational levels, would add valuable data to the conversation. It would great to see experimental models to measure the community health impact of a trained cadre of lay workers in selected districts or states. The experiments will neither be easy nor straightforward, but then game-changers seldom are.


Additional PHC (APHC) in eastern Bihar. The MBBS doctor assigned to the clinic lives in Patna. The rooms are filled with animal poop. For their healthcare needs, people in this village either call in the local informal providers, or walk to the nearest city, 10 km away, which has a PHC and private clinics. A bridge course trained provider might be useful for the villagers being "served" by this APHC [Image source: author]

Monday, March 4, 2019

Trekking over the Langtang trail over 5 days

Dates of our trek: 26 May to 1 June, 2018 (near perfect weather)

Day 3: Langtang village to Kyanjin Gompa
Difficulty level: I'm classifying this trail as a "special moderate". Easy because it's only 5 days long - 3 days uphill followed by 2 days downhill - and because like other “tea house trails”, it has comfortable, almost luxurious places to rest your weary bones every night. But it is difficult too because it has a few patches of starkly steep climbs. One of my favourite memories from the week is Rigveda craning her neck up to see the tea-house I was pointing at, the place where we were going to take our third and last break for the day. She stared at it for five seconds in silence, and then said - "let's not kid ourselves, Manjot, there's no way either of us is going to make it up there" (her exact words were, "dekho Manjot, ye hoga nai hum dono se, main bata rahi hoon". And this was the first day of our trek - things got much, much worse before they got better.

Why Langtang? 
Now that I am done talking about the painful part of the trek (I make no promises, it may come up again), I can list the joys - breathing the pure mountain air scented with a thousand unknown herbs, walking with your thoughts against a backdrop of birdsong and riversong, having your eyes fill up with more shades of green than you thought were possible, connecting with people and your self in ways that are just not possible in places that are not the Himalayas - we all know these elusive joys which call us to the mountains again and again. We chose the trek also because its duration was perfect. I  needed to take only a week's leave and sandwiching it between two weekends covered two travel days and one recovery day. And as many bloggers informed us, traveling through this part of Nepal is an opportunity to contribute to the rebuilding that is still going on after the devastating 2015 earthquake. 

Planning the trek: Rigs and I planned the trek for 6 months, but that's just us. We had a shared folder with packing lists, iterating itineraries, trek company quotes, best dates, debates on whether to do it alone or with guide or with guide and porter both. Contrary to some blogs that we read who strongly urge you to do the trail alone, we recommend taking a guide even if you're a reasonably experienced hiker, and even though the path is fairly well-marked. There are some confusing forks on which you might not get hopelessly lost - all paths eventually get to the main trail (haha this could be a deep insight) -  but you might end up spending a lot of time on a longer, less picturesque route that tires you out. A guide will give you an anxiety-free mind space to focus on your self and the beauty around you, educate you about local culture, tell stories and if you're lucky, even become your friend.  

Our itinerary: 
Three days uphill - Syafrubesi > Lama > Langtang > Kyanjin Gompa
Two days down hill - Kyanjin Gompa > Langtang > Syafrubesi
The actual trek is only 5 days, but our trip was 9 days inclusive of days to travel to and from the trail. 

Day 0: Arrive in Kathmandu. 
Friday, 25 May - We stayed at the Oasis hotel, which was nice and comfortable, and located in Thamel, which is downtown Kathmandu, and which is where everything is.

Day 1: Travel by road from Kathmandu (1400 m) to Syafrubesi (2100 m)
Saturday, 26 May - Not the most comfortable road trip, no matter how optimistic I try to be. But the views were lovely. We took the jeep on the way up, bus on the way down (day 7), but neither is for the fainthearted. We stayed at the Noryang guest house, which was lovely. 

Day 2/Trek day 1: Trek from Syafrubesi to Lama Hotel (2400 m) - about 7 hours of walking.
Sunday, 27 May - Breakfast at Noryang was lavish and delicious and we started our trail at 7.30 AM in a fairly lighthearted way, oblivious to the steep horrors awaiting us this day. The trail to Lama is a gentle forest walk through marijuana (yes) fields but does have a few extreme slopes. The river was a noisy walking buddy throughout this first day. There are four guest houses on the way that one can stop and rest at. We stopped for lunch at the Bamboo hut tea at the Tom and Jerry guest house. Both were lovely and we took fairly long breaks, which meant that it was nearly 5 PM by the time we arrived at Lama hotel, where - I'm not joking - found solar-powered hot showers. 

Happiness is finding a hot shower behind a green door 
Day 3: Lama hotel to Langtang (3400 m) - about 6 hours of walking. 
Monday, 28 May - I was woken up by a bird singing and thought, man, how predictable is that? As it happens so often in the mountains, I had a sudden flash of insight. That there are three big reasons why I like hiking through the Himalayas. One, life just becomes so incredibly simple - sadness is a blister on your toe, happiness is the sight of a flat walk after a mad uphill climb. Two, food is a million times more delicious. Literally everything you eat feels like poetry in food. Three, my eyes love the high def views - the stark yellows and reds in the flowers, the stark greens in the trees, the skies so perfectly blue (except when it rains when the skies become an equally perfect, high definition grey). 

We left Lama hotel soon after 8 AM, walked through villages with pretty names - Riverside, Ghodatabela, Thansyab, Gumba - and arrived at Langtang by 3 PM. Although this is probably the most significant height gain of this trail, it felt gradual and easy, perhaps also because we had toughened up. We stayed at the Glacier guest house, run by a lovely man named Tshering Dorje. I strongly recommend the place. 

Day 4: Langtang to Kyanjin Gompa (4000 m) - about 4 hours of walking. 
Tuesday, 29 May - This is perhaps the easiest hike of this trail, with very gentle slopes. You know you're getting close to the tree line - trees start to get fewer and shorter. This is the day we crossed the villages that got the worst of the 2015 earthquake. It was a sobering hour as we walked through the rubble. We arrived at Kyanjin Gompa just before 3 PM. This hamlet has a at least a dozen guest houses and they all look comfortable. We stayed at the Nayakhanga guest house which maybe has the best views in the village. It may or may not be Nayakhanga's fault that I got carried away and wrote a poem here. 

Day 5: Kyanjin Gompa to Lama hotel
Wednesday, 30 May - The climb down in this stretch is easier than the climb up, and views are as lovely. It was fun to say hello again to the tea houses we had stopped at two days previously. 

Day 6: Lama hotel to Syafrubesi
Thursday, 31 May - Spoke too soon, this downhill walk nearly succeeded in murdering all of my toes. It was such joy to get back to our dear old Syafrubesi, which as it turned out, has a natural hot spring where you can soak your feet and coax them back to life. 
Sometime on day 5


Day 7: Bus ride from Syafrubesi to Kathmandu
Friday, 01 June - I spent the seven hours alternating between napping and saying "wow, how pretty is that mountain!"

Day 8: Recovering and exploring Thamel 
Saturday, 02 June - I have two highlights from this day of recovery at Kathmandu. One, the hotel we chose this time, the Nepal Cottage Resort, felt like absolute luxury with the unlimited hot water and warm beds. It also has a beautiful garden. Two, we watched a fabulous Nepali band perform at the Purple Haze rock bar. I want to come back in live in Thamel for a week sometime, walking and eating and listening to music. In spite of the dust clouds. About that, Kathmandu - what is it with being global #5 in the most polluted cities in the world?! 

Day 9: Flight back home
Sunday, 03 June - My journal entry from this morning says: "So when can I go next to the Himalayas?"

Wednesday, February 27, 2019

Twelve days in Japan - Tokyo, Kyoto and Osaka

This winter, four of us - my brother, his wife, Prashanth and I - traveled to Japan for a two-week vacation. This was our second vacation together (the first was Germany in winter 2017). These two folks live in Sydney and naturally want to escape the December weather. And somehow, they've managed to sweet-talk me and Prashanth, both lovers of tropical weather, twice, into these super wintry holidays. We travel well together though - we're all an equal-ish mix of curiosity, laziness and affability.

If anyone tells you that a vacation to Japan is going to be unlike anything you’ve done before, believe them. We got back 8 weeks ago and we find ourselves constantly looking for Japanese food and culture in Bombay, like recovering junkies looking for the next fix. Short summary - yes it blew our minds, yes it was cold, no there were no cherry blossoms, yes the highlight of our trip was indeed the food, and yes we're dying to go again. In no particular order, here’s a list of things I loved in each city.

TOKYO
We stayed in two rather different neighborhoods over the 5 days that we were in Tokyo. Shinjuku north is the mad vibrant sort of place that I imagined all of Japan to be, so I’m glad we saw this before seeing other, slower but equally powerful places. The second neighbourhood we experienced was the Asakusa where we stayed at the Hotel Denchi. This is a quieter, residential sort of neighbourhood, with nice parks and shrines and museums. Here are my recommendations for Tokyo:

  • 9 hours Shinjuku north: If you’ve never stayed in a capsule hotel before, do yourself a favour and do it soon! Unless you're acutely claustrophobic, the space should not be concern: they’re not like MRI machines, which is how I imagined them – more like 5x the size of an MRI machine. I had three nights of amazing sleep in the capsule. There are a few minor inconveniences – you need to check in and out of your capsule every day, but they give you a roomy locker to keep all your stuff, and there are literally hundreds of coffee shops and restaurants next door.
  • The Onsen at Spa La Qua: We spent two afternoons (4 hours plus) here out of a 5-day trip. Need I say more?
  • Harajuku street: Very interesting neighborhood to walk around in – fantastic coffee, dozens of local designers to look at or buy from, stores with beautiful snacks and desserts, cafes where you can spend time with hedgehogs, cats or owls. We rolled our eyes at the weirdness of it all, then caved in an spent a lovely 30 minutes with some very sleepy hedgehogs. The famous Shibuya crossing is closeby, as is the Meiji shrine.
  • Meiji Shrine: High on all tourist lists, and with good reason.
  • Bar crawl with Alejandro (this is an airbnb experience) who took us on a very memorable walk around the izakayas on harmonica street.
  • Stationery stores: The city is a heaven for stationery lovers. We went to so many but Inkstand by Kakimori is perhaps my favourite. I've come back a person who now writes with fountain pens.
Top three food recommendations for Tokyo: Ramen at Zundo-ya in Shinjuku, Katsu curry at any of the CoCo Ichibanyas and burgers at Blacows.


KYOTO
Arriving in Kyoto after spending a few days in Tokyo feels like stepping back in time. It’s quieter, slower and has unbelievably picturesque streets that you can walk around in for hours, even in winter. I can understand how popular it is for cherry blossom enthusiasts – every street corner looks instagrammable. We stayed in Kyoto Inn Gion and I strongly recommend both the hotel and the neighborhood. If I live in this city for 10 years, I will not get tired of walking around. I recommend walking in the many interesting neighborhoods –Shirakawa, Pontocho, Nishiki market, Shijo dori  – over multiple days, at different times of the day,  because they look lovely in so many ways, especially the Shirakawa street. Shijo dori street has multiple dessert stores which have some truly exciting mochi-type sweet snacks which I recommend trying. We also participated in a tea ceremony which I enjoyed a lot. Another highlight of Kyoto was the music performance we watched at the Kyoto Muse. This city is famous for the breathtakingly beautiful shrines in the middle of massive gardens. The most popular ones are Fushimi Inari - made famous for the gazillion pictures of orange pillars on Instagram and Arashiyama - the one with the massive green bamboo trees, you’ve seen the pictures, you know what I’m talking about. We went to Fushimi Inari and I have to be honest, I did not enjoy it. The crowd was too overwhelming. But when we walked across the street from our hotel to the Yasaka shrine, which is not on any top 10 list, we experienced such perfect beauty and the silence that I will remember for a long time.

Top three food recommendations for Kyoto: Katsu curry at Kara-Kusa curry, Omurice at Fu-ka Ginkakuji, and Okominyaki absolutely anywhere.


OSAKA
They call it the foodies’ city, and they’re right. More than one person said to us that it’s impossible to have a disappointing meal in Osaka, so don’t bother to look at reviews. (I think this might be true for all of Japan. Apart from the one bento box I picked up at Osaka train station for the Osaka-Tokyo trip, every single meal in Japan is a lovely memory. Food just looks more beautiful and tastes more exciting in Japan). My recommendations for Osaka:
  • Morning meditation at the Osaka castle - Airbnb experience with Kuniatsu
  • Experience hidden Namba – Airbnb experience with Richard, an American ex-hotelier, who has lived in Japan for over 30 years, and just knows that he was a Japanese samurai in a past life. We rang the new year with this dude and a bunch of very, very friendly strangers
  • Onsen at Spa world – yes, onsen again. Onsens are definitely among my top 3 Japanese experiences.

OUR ITINERARY
Sunday, 23 December: Arrived in Tokyo
23 – 25 December to: Tokyo (2 days, 3 nights)
Wednesday, 26 December: Train to Kyoto (about 5 hours)
26-29 December: Kyoto (4 days, 4 nights)
Sunday 30 December: Train to Osaka (about 15 minutes)
30 December 2018 to 01 January 2019: Osaka (3 days, 3 nights)
Wednesday, 2 Jan 2019: Train to Tokyo
2-5 January: Tokyo again (3 days, 3 nights)
Saturday, 5 January: Flight back to Bombay


Saturday, February 23, 2019

At Nayakhanga (day 4 of the Langtang trail)



What does anything matter
If every once in a while
I can come to this place
Even if it is in my own head - travel cheap and easy 

Breathe in this pine scented air
Watch the sun set over snowed mountains
Hear yak bells and singing rivers 
Feel the mental batteries reboot


Really, what does the chaos in the real world matter
When I know that this place exists
that I and this mountain live on the same planet
that we can meet each other again
and listen to Nepali songs together
songs that I don't understand and yet somehow understand

Friday, February 22, 2019

I think I may have understood what procrastination is all about (thank you Dr Oakley!)

I used to love writing. I wrote about the mountains I climbed, imagining scores of people using my blog to plan their own treks. I wrote about my disastrous dates (names removed), imagining people reading and chuckling. It was mostly friends and family who read and loved my blog - they said they did and I chose to believe them. Every once in a while, a stranger would pop in here and leave a flattering comment that would leave me glowing for weeks.

At some point, I became aware that I was an only an average sort of writer, not brilliant. It wasn't a sudden realization, brought on by any specific criticism, but it came insidiously and took away all the crazy joy I used to get out of a very loved routine – keyboard clacking, throwing a bunch of random thoughts down on a document, rereading a dozen times, hitting publish, nagging folks to read and enjoying the attention. It just stopped being fun. My frequency of posting on my blog is a very telling graph:

The number of posts I wrote from 2007 to 2018

My brother, who thinks a lot about how powerful the act of creating is and how much it makes us who we want to become, continued to gently remind me to write, and always said “Great!” whenever I said I would write soon. He also continued to renew the subscription on my domain, year on year, without ever saying anything about it. 

I wanted to write. In May 2018, a friend and I went on a gorgeous trek in Nepal, and even as I was climbing those breathtakingly beautiful trails, I was thinking – this will break my writer’s block for sure. I know I will want to write about this. We got back on the 2nd of June, and I started to write about the Langtang trail in July. I wrote a few words, put a few pictures in. And stopped. Every night, I would put this on my to-do list – “Finish Langtang post”. Every morning I would see that entry, and this is it what would happen:
  • 7 AM: I’ll start my day with Brainpickings.org, that should inspire me to write
  • 8.30 AM: Let me make some fresh coffee and start writing
  • 9 AM: I’ll tidy up my work desk first, then write about Langtang before I open my work 
  • 9.30 AM: Let me quickly check email to see if something important has come in that might need a response from me
  • 7 PM: I’m exhausted. I’ll scroll through Facebook and Instagram for a bit, that’ll help me unwind and then I’ll write
  • 8 PM: I don’t feel like writing, it’s been such a long day. I’ll have dinner and put Langtang on my to-do list for tomorrow.
And so it went for 3 weeks. And then I decided to stop thinking about Langtang because it was too painful. I decided I don’t really need to write, I have a pretty fulfilling life as it is.

And then, two weeks ago, I started a course called “Learning How to Learn” (LHTL) - often cited as the most popular among all MOOCs. I have a tendency to be hyperbolic, but I don’t think I’m exaggerating when I say this course has probably changed my life. And within this course, the lesson on Procrastination which I want to summarise here, so that I can remember it. 

Everyone I know procrastinates. We acknowledge it, with shame, sheepishness, sometimes even a weird sort of pride. As I went through the course, the mechanics of procrastination started to make sense. I see patterns in my life and something is starting to shift in my brain. It also helps that thanks to Simon Sinek, I got intensely interested in neurochemicals, so the procrastination circuit, as explained in LHTL, makes even more sense. This is what the circuit looks like, with some examples from my life:

The procrastination circuit [source: my notes from Learning How to Learn]

So here are the top four things I’ve learned from the LHTL’s section on procrastination:
  1. Will power is a limited resource. Using it can deplete it, so it needs to be used strategically. You only need to apply it at point X – between Cue and Habit – and learning to identify the cues is the way to streamline the use of your will power
  2. Discomfort is your friend. When you’re trying to manage procrastination, the discomfort you feel when you do not follow your usual cue>habit cycle will be significant. Every time, multiple times. But knowing this discomfort, acknowledging it, being okay with it, not trying to push it away is the best gift you can give yourself. This discomfort is building new brain circuits and so it is your friend (Vipassana flashback!)
  3. Failing is okay, as long as it is with awareness. Anytime you try to break the cue>habit, one of two things will happen. You will either not perform the habit that the cue wants you to do – let’s call this success. Or you will follow your usual pattern and perform the habit – let’s call that failure. Success builds new habit circuits, so that over time and repetition, the discomfort of the new habit will lessen. Failure will increase your understanding of your self and your patterns so that next time you try to break the cue>habit pattern, this understanding will make the process slightly, infinitesimally, easier. So both outcomes are okay, but you need to be aware of what is going on.
  4. Celebrate when you’re successful. Reward yourself. Sometimes the reward is the just the feeling that OMG, I did it! Savour that feeling. The way I’m feeling right now because I finished this piece.

Final takeaway: just start. Choose a random self-experiment of breaking one procrastination habit. My experiment – I will write something every day. It will be uncomfortable, but I will do it.


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