It is not surprising that India has a booming healthcare sector, considering that a population of 1.35 billion in 2018 is likely to exhibit myriad morbidities (World Bank, 2018). With a three-fold increase in the healthcare market and governmental projections pushing a 372 billion USD mark in 2022, the sector is ready for significant technological interventions. (IBEF, 2019). On the downside however, the sector is beleaguered by concerns that range from access barriers and poor doctor-patient ratio to affordability and poor healthcare infrastructure. Artificial intelligence (AI) comes with a promise of not only overcoming a majority of these barriers, but also eliminating predispositions, such as the recency bias, in medical sciences. Riding the investment wave AI—robotics and Internet of Things (IoTs) can revolutionise healthcare.
Healthcare concerns can be broadly classified into those which are predictive in nature—pre-empting a problem and providing a solution to abrogate the issue; and, prescriptive, where a treatment is offered based on an informed decision. When AI is deployed to prepare algorithms that help map patterns by collecting and analysing gathered data—both spatial and temporal, it is found that it can provide astounding results in preparing a response ahead of time and influencing outcomes. From early detection of diseases based on analysis of past data, to decentralised diagnostic testing, AI can singularly alleviate healthcare problems in rural and remote areas. AI algorithms are able, with a certain degree of precision, to screen diseases, which can help triaging high priority cases, enhancing the productivity of healthcare professionals.
In India, companies such as Artelus, a Bangalore based AI enabled healthcare unit, works to provide an image-based early detection facility for diabetic retinopathy . The Deep Learning and AI based setup in Artelus can help identify at a primary screening, lesions or abnormalities present in fundus images and report it to the doctor, making it impactful for areas that lack this facility. These healthcare capacities extend beyond the boundaries of hospitals and specialised clinics, reduce cost and improve health outcomes. There are many such applications for various anatomical disorders world over, such as IBM Watson for oncology and many private hospitals in India, such as the Manipal group of hospitals, make use of such interfaces.
Interestingly, AI can also screen mental disorders in its early stages, like depression. Wysa, a bot developed by Bangalore based start-up Touchkin, is delving into the domain of emotional wellness. Supported by human coaches, the bot helps cure depressive thoughts (wysa.io).The app records and analyses various physiological factors like sleep patterns, blood sugar levels and other behavioural insights and predicts the user’s mental health. In the event that the bot identifies an individual who needs intensive care, it refers the case to professionals, who can then intervene.
Niramai, a Bengaluru based healthcare start-up has developed a non-invasive, radiation free breast cancer detection software that uses a high resolution thermal sensing device and a cloud hosted analytics solution for screening thermal images that accurately leads to the early detection of tumours. Orbuculum, another start-up in Bengaluru analyses genomic data to predict a gamut of diseases.
Telangana in fact, has adopted a cloud-based analytics tool developed by Microsoft, for the state’s Rashtriya Bal Swasthya Karyakram, to reduce avoidable blindness among children by screening them for the ailment. Thus predictive AI usage in healthcare can provide actionable insights based on available data and thus improve healthcare penetration.
Prescriptive analytics on the other hand, make use of machine learning to determine the best solution or outcome among various courses of action. For instance, an AI algorithm in IBM Watson for oncology will use information from relevant literature to assess the information from a patient’s medical record and throw up potential treatment options ranked by level of confidence. The oncologist can then use the results along with the supporting evidence to arrive at the appropriate treatment option. Such AI interfaces aid human decision making for doctors and health administrators to use critical data to support clinical, financial and operational decisions. It can lower the cost of healthcare, improve patient efficiency and mitigate operational risks.
This technology has found its way into hospitals in India as well. Manipal uses IBM Watson for Oncology. Max Healthcare,India has deployed the GE Healthcare’s web-based radiology information system—the Centricity RIS-IC. Integrated with the GE -picture archive and communication system (PACS), the programme addresses a healthcare unit’s evolving radiology workflow to enable seamless access to images like X-Ray, MRI and more for patients across locations. It can therefore be used to create an integrated customer record of patients. Fortis Hospital, Bengaluru has partnered with Phable, a healthcare start-up in India, to provide an App to the patients that allows for constant monitoring by the doctor in the event any new symptoms emerge and can also help patients manage medication, tests, diet, exercise etc.
The medical equipment industry are also using AI and machine learning to develop smart wearables and insertables that gather individual data and detect anomalies. The US drug major Abott has launched an Insertable Cardiac Monitor (ICM) that can alert users about irregular heartbeats (arrhythmias) on their smartphone screen (cardiovascular.abbott). Ten3T, another Indian healthcare start-up has launched a wearable device named ‘Smart Patch’ that inter alia measures the patients’ temperature, pulse and blood pressure and provides real time monitoring facility (ten3thealth.com). AI also delves into solving problems related to the pharma supply chain with tools streamlining the entire process from drug generation to delivery. Pharmarack, a Pune based start-up has developed a tool to automate the sales and operational processes of pharma companies (pharmarack.com). It offers management solutions from the origin of order to its completion, in a seamless platform to process, track, and settle all orders, creating complete visibility of business operations in real time.
The AI and machine learning has begun to partner with the medical insurance sector as well. Embedded into existing insurance frameworks, the platform helps insurers to automate and expedite the process, minimising delays and frauds. ICICI Lombard and HDFC bank with their AI and Natural Language Processing (NLP) based chat bots named MyRA and SPOK, respectively, are using AI to categorise, prioritise and respond to customer emails and mine appropriate information for an improved operational efficiency (myralabs.com;
Dhawan 2018) .
Ethical Concerns in AI Healthcare
In 2008, Google Flu Trends (GFT), began aggregating and analysing big data from a range of countries based on Google search queries. GFT then went on to predict or ‘nowcast’ the onset on flu outbreaks days before they were reported by the global Centres for Disease Control and Prevention (Lazer and Kennedy, 2015). However, GFT failed to accurately predict the 2009 global swine flu pandemic, as its algorithm over relied on the Google search patterns rather than the traditional reporting of the disease. In 2013, the GFT failed again, missing predictions by 140 per cent at the peak of the flu season. The project was thereafter closed. It is true that big data is competent to model disease spread and identify emergencies, way faster than traditional methods, but the method and the data used becomes critical in identifying a trend—which is why the GFT lost out. AI and machine learning therefore, needs to be understood in the perspective of its own set of challenges. Apart from the data accuracy concerns, a faulty algorithm can distort the results. In a scenario where humans begin to depend on AI for its decisions, such errors can lead to critical drawbacks in healthcare.
AI, if handled improperly can result in data leaks, which would lead to privacy violations. In India the consent forms for data sharing are not mandatorily filled by the healthcare units—and patients too are barely aware of its need. In practice, doctor-patient confidentiality is in the realm of ethics. Therefore, there is always a chance that the profile of patients can be exploited by companies and consequent data breach can lead to an erosion of trust among the general public. For instance, in 2016, a Mumbai based diagnostic laboratory Health Solutions had to remove over 35,000 medical records of patients which included HIV reports, when its data leaked (Indian Express, 2019). Such breaches are a constant threat that AI needs to combat in order to maintain patient confidentiality.
Then of course there is the single language predisposition that AI holds, where English predominates, making it difficult for the technology to penetrate rural areas. With a huge internet connectivity of over 566 million people in 2018 (The Economics Time, 2019), AI can make greater headway if vernacular usage is encouraged.
Importantly, an AI enabled system thrives on data—generation of poor quality data coupled with poor digital infrastructure and storage can skew results, rendering programmes ineffective. In India lack of trained professionals for data handling also impedes the penetration of AI in this sector. Also, the focus of AI in healthcare in India is nascent and fairly narrow, with disease specific solutions.
Way Forward
AI has significant scope in developing solutions in bettering the lives of humans, and healthcare is a priority area of research. Despite the many challenges AI and machine learning exhibit at present, ground is being made for larger and more accurate predictive and prescriptive programmes. An ambient policy framework by the Indian government that makes for favourable investments in the AI and machine learning sector can help augment the paucity of quality healthcare professionals in many locations of the nation
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The United Nations has shaped so much of global co-operation and regulation that we wouldn’t recognise our world today without the UN’s pervasive role in it. So many small details of our lives – such as postage and copyright laws – are subject to international co-operation nurtured by the UN.
In its 75th year, however, the UN is in a difficult moment as the world faces climate crisis, a global pandemic, great power competition, trade wars, economic depression and a wider breakdown in international co-operation.
Still, the UN has faced tough times before – over many decades during the Cold War, the Security Council was crippled by deep tensions between the US and the Soviet Union. The UN is not as sidelined or divided today as it was then. However, as the relationship between China and the US sours, the achievements of global co-operation are being eroded.
The way in which people speak about the UN often implies a level of coherence and bureaucratic independence that the UN rarely possesses. A failure of the UN is normally better understood as a failure of international co-operation.
We see this recently in the UN’s inability to deal with crises from the ethnic cleansing of the Rohingya Muslims in Myanmar, to civil conflict in Syria, and the failure of the Security Council to adopt a COVID-19 resolution calling for ceasefires in conflict zones and a co-operative international response to the pandemic.
The UN administration is not primarily to blame for these failures; rather, the problem is the great powers – in the case of COVID-19, China and the US – refusing to co-operate.
Where states fail to agree, the UN is powerless to act.
Marking the 75th anniversary of the official formation of the UN, when 50 founding nations signed the UN Charter on June 26, 1945, we look at some of its key triumphs and resounding failures.
Five successes
1. Peacekeeping
The United Nations was created with the goal of being a collective security organisation. The UN Charter establishes that the use of force is only lawful either in self-defence or if authorised by the UN Security Council. The Security Council’s five permanent members, being China, US, UK, Russia and France, can veto any such resolution.
The UN’s consistent role in seeking to manage conflict is one of its greatest successes.
A key component of this role is peacekeeping. The UN under its second secretary-general, the Swedish statesman Dag Hammarskjöld – who was posthumously awarded the Nobel Peace prize after he died in a suspicious plane crash – created the concept of peacekeeping. Hammarskjöld was responding to the 1956 Suez Crisis, in which the US opposed the invasion of Egypt by its allies Israel, France and the UK.
UN peacekeeping missions involve the use of impartial and armed UN forces, drawn from member states, to stabilise fragile situations. “The essence of peacekeeping is the use of soldiers as a catalyst for peace rather than as the instruments of war,” said then UN Secretary-General Javier Pérez de Cuéllar, when the forces won the 1988 Nobel Peace Prize following missions in conflict zones in the Middle East, Africa, Asia, Central America and Europe.
However, peacekeeping also counts among the UN’s major failures.
2. Law of the Sea
Negotiated between 1973 and 1982, the UN Convention on the Law of the Sea (UNCLOS) set up the current international law of the seas. It defines states’ rights and creates concepts such as exclusive economic zones, as well as procedures for the settling of disputes, new arrangements for governing deep sea bed mining, and importantly, new provisions for the protection of marine resources and ocean conservation.
Mostly, countries have abided by the convention. There are various disputes that China has over the East and South China Seas which present a conflict between power and law, in that although UNCLOS creates mechanisms for resolving disputes, a powerful state isn’t necessarily going to submit to those mechanisms.
Secondly, on the conservation front, although UNCLOS is a huge step forward, it has failed to adequately protect oceans that are outside any state’s control. Ocean ecosystems have been dramatically transformed through overfishing. This is an ecological catastrophe that UNCLOS has slowed, but failed to address comprehensively.
3. Decolonisation
The idea of racial equality and of a people’s right to self-determination was discussed in the wake of World War I and rejected. After World War II, however, those principles were endorsed within the UN system, and the Trusteeship Council, which monitored the process of decolonisation, was one of the initial bodies of the UN.
Although many national independence movements only won liberation through bloody conflicts, the UN has overseen a process of decolonisation that has transformed international politics. In 1945, around one third of the world’s population lived under colonial rule. Today, there are less than 2 million people living in colonies.
When it comes to the world’s First Nations, however, the UN generally has done little to address their concerns, aside from the non-binding UN Declaration on the Rights of Indigenous Peoples of 2007.
4. Human rights
The Human Rights Declaration of 1948 for the first time set out fundamental human rights to be universally protected, recognising that the “inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world”.
Since 1948, 10 human rights treaties have been adopted – including conventions on the rights of children and migrant workers, and against torture and discrimination based on gender and race – each monitored by its own committee of independent experts.
The language of human rights has created a new framework for thinking about the relationship between the individual, the state and the international system. Although some people would prefer that political movements focus on ‘liberation’ rather than ‘rights’, the idea of human rights has made the individual person a focus of national and international attention.
5. Free trade
Depending on your politics, you might view the World Trade Organisation as a huge success, or a huge failure.
The WTO creates a near-binding system of international trade law with a clear and efficient dispute resolution process.
The majority Australian consensus is that the WTO is a success because it has been good for Australian famers especially, through its winding back of subsidies and tariffs.
However, the WTO enabled an era of globalisation which is now politically controversial.
Recently, the US has sought to disrupt the system. In addition to the trade war with China, the Trump Administration has also refused to appoint tribunal members to the WTO’s Appellate Body, so it has crippled the dispute resolution process. Of course, the Trump Administration is not the first to take issue with China’s trade strategies, which include subsidises for ‘State Owned Enterprises’ and demands that foreign firms transfer intellectual property in exchange for market access.
The existence of the UN has created a forum where nations can discuss new problems, and climate change is one of them. The Intergovernmental Panel on Climate Change (IPCC) was set up in 1988 to assess climate science and provide policymakers with assessments and options. In 1992, the UN Framework Convention on Climate Change created a permanent forum for negotiations.
However, despite an international scientific body in the IPCC, and 165 signatory nations to the climate treaty, global greenhouse gas emissions have continued to increase.
Under the Paris Agreement, even if every country meets its greenhouse gas emission targets we are still on track for ‘dangerous warming’. Yet, no major country is even on track to meet its targets; while emissions will probably decline this year as a result of COVID-19, atmospheric concentrations of greenhouse gases will still increase.
This illustrates a core conundrum of the UN in that it opens the possibility of global cooperation, but is unable to constrain states from pursuing their narrowly conceived self-interests. Deep co-operation remains challenging.
Five failures of the UN
1. Peacekeeping
During the Bosnian War, Dutch peacekeeping forces stationed in the town of Srebrenica, declared a ‘safe area’ by the UN in 1993, failed in 1995 to stop the massacre of more than 8000 Muslim men and boys by Bosnian Serb forces. This is one of the most widely discussed examples of the failures of international peacekeeping operations.
On the massacre’s 10th anniversary, then UN Secretary General Kofi Annan wrote that the UN had “made serious errors of judgement, rooted in a philosophy of impartiality”, contributing to a mass murder that would “haunt our history forever”.
If you look at some of the other infamous failures of peacekeeping missions – in places such as Rwanda, Somalia and Angola – it is the limited powers given to peacekeeping operations that have resulted in those failures.
2. The invasion of Iraq
The invasion of Iraq by the US in 2003, which was unlawful and without Security Council authorisation, reflects the fact that the UN is has very limited capacity to constrain the actions of great powers.
The Security Council designers created the veto power so that any of the five permanent members could reject a Council resolution, so in that way it is programmed to fail when a great power really wants to do something that the international community generally condemns.
In the case of the Iraq invasion, the US didn’t veto a resolution, but rather sought authorisation that it did not get. The UN, if you go by the idea of collective security, should have responded by defending Iraq against this unlawful use of force.
The invasion proved a humanitarian disaster with the loss of more than 400,000 lives, and many believe that it led to the emergence of the terrorist Islamic State.
3. Refugee crises
The UN brokered the 1951 Refugee Convention to address the plight of people displaced in Europe due to World War II; years later, the 1967 Protocol removed time and geographical restrictions so that the Convention can now apply universally (although many countries in Asia have refused to sign it, owing in part to its Eurocentric origins).
Despite these treaties, and the work of the UN High Commission for Refugees, there is somewhere between 30 and 40 million refugees, many of them, such as many Palestinians, living for decades outside their homelands. This is in addition to more than 40 million people displaced within their own countries.
While for a long time refugee numbers were reducing, in recent years, particularly driven by the Syrian conflict, there have been increases in the number of people being displaced.
During the COVID-19 crisis, boatloads of Rohingya refugees were turned away by port after port. This tragedy has echoes of pre-World War II when ships of Jewish refugees fleeing Nazi Germany were refused entry by multiple countries.
And as a catastrophe of a different kind looms, there is no international framework in place for responding to people who will be displaced by rising seas and other effects of climate change.
4. Conflicts without end
Across the world, there is a shopping list of unresolved civil conflicts and disputed territories.
Palestine and Kashmir are two of the longest-running failures of the UN to resolve disputed lands. More recent, ongoing conflicts include the civil wars in Syria and Yemen.
The common denominator of unresolved conflicts is either division among the great powers, or a lack of international interest due to the geopolitical stakes not being sufficiently high. For instance, the inaction during the Rwandan civil war in the 1990s was not due to a division among great powers, but rather a lack of political will to engage.
In Syria, by contrast, Russia and the US have opposing interests and back opposing sides: Russia backs the government of the Syrian dictator Bashar al-Assad, whereas the US does not.
5. Acting like it’s 1945
The UN is increasingly out of step with the reality of geopolitics today.
The permanent members of the Security Council reflect the division of power internationally at the end of World War II. The continuing exclusion of Germany, Japan, and rising powers such as India and Indonesia, reflects the failure to reflect the changing balance of power.
Also, bodies such as the IMF and the World Bank, which are part of the UN system, continue to be dominated by the West. In response, China has created potential rival institutions such as the Asian Infrastructure Investment Bank.
Western domination of UN institutions undermines their credibility. However, a more fundamental problem is that institutions designed in 1945 are a poor fit with the systemic global challenges – of which climate change is foremost – that we face today.