Ten years ago, to this day, much to the consternation and befuddlement of some of my friends and well-wishers, I chose to pursue my MD training in Preventive and Social Medicine, ahead of more conventional career pathways in surgery, anesthesia, or other clinical subjects. Since then, I have wondered many times, what the counterfactual would look like… but, on reflecting on my eclectic, meandering pathways over the years, I cannot say I have too many regrets with the road I chose to traverse. After all, I have always been a bit of a gadfly, so why be anything else when it came to choosing career trajectories?

Looking back, there are so many things in life that have been linked to this career decision that I am eternally grateful for. Prime amongst them has been the privilege to meet my significant other, with whom I would have never connected had it not been for my career choice. There are so many friendships and associations that would not have blossomed but for this decision. I seriously doubt if I would have been able to train at the world’s premier institute had it not been for this career choice. I would not have been able to indulge the inner infectious diseases nerd in me, work in close approximation with the highest levels of policymaking in the nation, work on research projects that changed policies, and learn a million and one lessons about life, the world, and the universe.

When I was a somewhat lost MD student in my twenties, grappling with whether I had made a terrible mistake, I could hardly have imagined where this path would take me. But I can trace a thread running through these years: an almost relentless conviction that the most pressing health problems facing our nation, our world, required not clinical brilliance in the clinic, but rigorous thinking about systems, societies, and the structural forces that shape who gets sick and who gets well.

During my time at the Public Health Foundation of India, I was first exposed to the One Health framework, an approach that recognizes the deeply interconnected nature of human, animal, and environmental health. This was revelatory. At PHFI, I spent my time trying to understand the epidemiology of zoonotic spread of brucellosis and bovine tuberculosis across rural and peri-urban India, and suddenly I had a conceptual framework that made sense of the messiness I was observing on the ground. Animals in cramped conditions were fed antibiotics for growth promotion. Farmers handling infected livestock without protective equipment were getting sick. Wastewater from pharmaceutical manufacturing was contaminating local water sources. These were not separate problems requiring separate solutions: they were threads in the same fabric.

By 2017, when I joined the Indian Council of Medical Research’s National Institute of Cholera and Enteric Diseases in Kolkata (which has been renamed as National Institute of Research in Bacterial Infections – NIRBI), I had begun to develop a real understanding of how antimicrobial resistance unfolds across populations, across sectors, and across borders.

Sometimes, I indulge in wondering what I would tell my ten-year younger self, were I to talk to him today. And then I wonder, given how hard-headed I am, would I have listened to the (surely) cynical advice grizzled old me would be giving out? I would have perhaps used some of the time I whiled away a little better. Invested in learning some of the core skills areas that I am still struggling with. Played the “game” a little more carefully, taking care to be a little less cavalier about ticking people off (or not!). I am immensely grateful to be standing where I am today, and I realize that this is a sum total of all the decisions I made, all the right choices, the wrong choices, the choices never made, and the choices that were ignored. Each and every one of these steps has taken me towards becoming the person and professional that I am today. I must say that I am all the more enriched for it.

Knowing what I do about the futility of a large proportion of my MD training, I sometimes debate if I still would make the same career choice were I to go back in time and redo this decision. Given how public health and clinical medicine are divergent career choices, it is entirely possible that had I chosen a different career pathway, I would not have arrived at this junction today. Also, given that public health skills are not the forte of Preventive and Social Medicine graduates only, it is also possible that I could have retrained myself, and found a very different niche in this professional space.

Given my personal, political, moral, and policy convictions, one thing that is clear to me is that whatever career pathway I had chosen ten years ago, I would have ended up doing public health work in some shape, form or fashion. I have always been convinced of the power of preventive care over curative care, comprehensive primary health approaches over tertiary centers of excellence, and the need to address population health needs to ameliorate the health conundrums facing the nation.

And then there were the pandemic years…

By early 2020, I was in New Delhi, working at the headquarters of the Indian Council of Medical Research when COVID-19 broke out. I found myself drafted to manage the Secretariat of the National Task Force on COVID-19, the apex policymaking body directing India’s pandemic response. I was responsible for rapid evidence synthesis to support real-time decision-making. In those frantic early months, as the world was grappling with an entirely novel pathogen, I published a rapid review of COVID-19 epidemiology and public health response that was cited hundreds of times and helped shape India’s initial policy response. But it was during the second wave of the pandemic, when India’s health systems were crippled by a shortage of oxygen, that I learned the most humbling lesson: policy papers and evidence syntheses mean nothing if you’re not on the ground, delivering oxygen concentrators to communities that are suffocating for lack of it. That experience fundamentally shifted something in my thinking about what public health work actually means.

On a lighter note, this experience was also how my dear friend Anup and I came up with a new framework of estimating the effectiveness of public health interventions. We compared proposed public health interventions and asked if it was more or less effective than standing in front of ICMR and distributing hand sanitizers. Ashwagandha for COVID immunity? Ivermectin? Fancy drugs that cost a bomb for severe COVID-19? Our framework stoof the test of time!

It was against this backdrop that I decided to move to the US to pursue my PhD at Johns Hopkins Bloomberg School of Public Health. My doctoral research is centered on understanding the preferences and behaviors of both formal and informal prescribers, and the patients and caregivers who seek out antibiotics, in rural India. I’m investigating the question that has animated much of my research over the years: what drives antibiotic overuse at the community level, and how can we address it without simply imposing top-down restrictions that ignore local realities? This work has taken me back to the villages and towns of India repeatedly, sitting with pharmacists, clinicians, and families, trying to understand how they navigate a healthcare landscape that is fractured, inequitable, and often fails them.

Over the past three years, my research focus has also sharpened around questions of power, knowledge, and epistemic justice in how we construct and disseminate global health knowledge itself. I contributed to work on using anti-oppressive teaching principles in graduate global health courses at Johns Hopkins, grappling with how a field born out of colonialism and tropical medicine continues to perpetuate colonial structures and ways of knowing. I was involved in developing pedagogical approaches that interrogate these very foundations. I’ve also been thinking deeply about what decolonization of global health actually means; not merely as a diversity and inclusion effort, but as a fundamental dismantling of the feudal structures that continue to concentrate knowledge, funding, and agenda-setting power in the institutions of the Global North.

To be clear, though, I am skeptical of how DEI has often been deployed, particularly in American academia and institutions. DEI in practice has frequently become a box-ticking exercise; a veneer of diversity that papers over the persistence of structural inequalities while providing moral cover to institutions that remain fundamentally unchanged. Adding a few faces from the Global South to grant committees, hiring a diversity officer, or mandating unconsciousness training does nothing to dismantle the feudal architecture of global health itself. In fact, it can paradoxically entrench it further by lending legitimacy to institutions that continue to hoard resources, control agendas, and position themselves as the arbiters of knowledge. True decolonization isn’t about making oppressive systems slightly more inclusive; it’s about recognizing and fundamentally challenging the power imbalances that allow those systems to persist in the first place. It requires the kind of honest reckoning with structural injustice that makes many institutions uncomfortable; and that is precisely why it remains so rare in practice. Anyway. That is a post for another day.

One thing that I look back and identify, almost always, is the serious lack of role models most MD graduates in Preventive and Social Medicine experience. I was in a uniquely empowered position, and went to training programs with incredible individuals, both in the personal and professional spaces. When I look around, however, I see most PSM MD graduates are far from being that fortunate. This drove me to start writing the Careers in PSM series on this blog, and eventually, led me to consider the idea of consolidating these experiences and anecdotes about public health careers to enable and empower the next generation of public health students.

With that in mind, I decided to work with a friend to launch a website dedicated to providing not just MD students, but a broader swathe of students, both from medical and non-medical backgrounds, with real life evidence and role models to emulate and build their public health careers. This work has evolved; the Global Public Health eXchange (GPHX) now exists as both a website and a podcast platform where students and practitioners of public health come together to exchange ideas and expertise, learn from one another, and co-create a community of practice. It remains a nascent endeavor, but one I believe is more necessary than ever as we grapple with how to reimagine public health education itself and make it truly decolonial.

The last decade and a half have seen me take a long and tortuous road in my career pathway. From being a somewhat lost MD student wondering if I’d made a terrible mistake, through my work as a scientist at the Indian Council of Medical Research, my engagement with policymaking at the highest levels of government during the COVID-19 pandemic, to becoming, well, a somewhat less lost PhD student at Johns Hopkins, trying to hold together the tension between rigorous epidemiology and the lived realities of the communities I study. Somehow thirteen years have slipped by. And you know what, despite everything I feel on the rare “off day,” I would not have it any other way. The record shows, I took the blows and did it my way.

Origins: Abandonment and Survival

Marc’s life begins in the throes of rejection. His biological mother abandons him, and he enters the foster system in Montreal, exchanging the hope for family affection with the reality of a series of foster situations that range from stern to outright oppressive. Some homes, he describes, evoked for me the nastiest images conjured by the Dursley family from Harry Potter. One particular family never calls him by name, makes him shoulder all household work, and sends him off on errands designed to exclude him from any shared joy. The incident that haunts the reader occurs on Christmas Eve, when young Marc is sent on a punishing errand tending to embers outdoors, just so that the family celebrations can proceed without the unwanted intrusion of a foster child.

Marc’s recounting does not slip into melodrama. Instead, he describes plainly the cruelty and hardship, letting the reader feel every bit of the silence and alienation he endured. Things reach a breaking point; feelings of powerlessness and rage, compounded over time, provoke a response where Marc arms himself and contemplates shooting the woman of the house who had made his life miserable. Thankfully, at the last moment, he pulls back, recognizing the gravity of the irreversible act and that such violence would destroy any hope for a future.

Adolescence: Shortcuts and Chaos

Moving into adolescence, Marc embarks on a haphazard journey through manual work and increasingly illicit activities. Starting out with construction work, he soon discovers that making money through shortcuts holds its own attractions. What begins with a bit of shoplifting, mostly jeans and personal items, quickly escalates into grander schemes. He sells the stolen goods to friends at half price, building up a modest fortune, and before long, he becomes skilled at breaking and entering homes, even learning how to bypass alarm systems and security. Then, Marc starts accepting “commissions”: he takes requests for particular items from friends, thus entering a more organized form of petty crime.

Parallel to this, Marc’s engagement with substances follows a familiar but dangerous path. Cigarettes lead to alcohol, then marijuana, and eventually to cocaine and other drugs. There is a specific point in the story where Marc describes consuming between five and eight grams of cocaine per day. This volume is not just startling; it also speaks to the impossibility of sustaining such a lifestyle for any length of time. Throughout these passages, Marc does not offer excuses for his behavior, nor does he unnecessarily romanticize or vilify this period. If anything, the tone retains an underlying sense of longing. All he ever wanted, it seems, was acceptance and family, something denied him in childhood and which he seeks through increasingly risky behaviors.

Biker Brotherhood: Family By Another Name

Marc’s first genuine sense of belonging comes from an unexpected quarter: he is drawn into the world of motorcycles through his girlfriend Maria’s brother, the leader of a biker gang. The brotherhood is insular and tight knit; Marc, with his love for bikes and general resourcefulness, is welcomed and soon given small jobs. He ferries messages, makes contacts, and negotiates connections. Because of his talents, and sometimes, his naivete, Marc is able to enter spaces where other bikers would not venture. As his usefulness grows, he is entrusted with more, holding drugs and guns, handling larger sums of money, and ultimately being swept up in the kinetic energy of gang life.

Marc’s life during this time is described in a manner that is almost breathless. Days bleed into nights in a haze of movement, substances, deals, and quick cash. The realization that something is deeply wrong comes to him with abrupt clarity; he is burning through both his life and the drugs at an unsustainable pace. Seeking to claw his way out, Marc undertakes a cold-turkey detox in the freezing woods. Like everything else in the book, this pivotal moment is presented without excessive drama, almost prosaic in its staid and matter-of-fact tone. However, the reader does not run the risk of missing out on how this short description is a key turning point in the book.

Turning Point: From Montreal to Paris and MSF

Leaving the biker world behind, Marc relocates to Paris. Here, he finds new meaning by joining Médecins Sans Frontières (MSF), known more commonly as Doctors Without Borders. Initially, Marc’s work situates him squarely in the heart of domestic projects. He is sent as part of an MSF crew to help refurbish old Parisian apartment blocks plagued by lead paint, a public health spell breaker if ever there was one. Marc takes to the work, appreciating the chance to help people and, not least, to be part of a team doing meaningful labor.

That restlessness, the urge to do more, soon grips him again. Marc wants to be on the frontlines, to fight not only physical deprivation but also global inequity, humanitarian crises, and disease. With this in mind, he is transferred to Malawi, not as a doctor, but as a logistician, where he will learn the basics of building and managing emergency health projects.

Malawi and Baptism by Fire: Cholera, Construction, Crisis Response

Malawi is described as an unrelenting test of human endurance and improvisational skill in Marc’s telling. He finds himself in charge of setting up a cholera treatment center, a daunting responsibility. He must coordinate large teams, secure materials, create supply chains, and help deliver critical medical services in conditions that are frequently unstable and unpredictable. Marc’s account is detailed and pragmatic. He does not romanticize the experience. Instead, the narrative is rich with insights into what it actually takes to do humanitarian fieldwork effectively. The pressure does not let up, and success is measured in intermittent small victories, interspersed with dollops of failures and frustrations.

Marc’s approach to humanitarian work is deeply pragmatic, sometimes to the point of antagonism toward official policy. He relates anecdotes that highlight his willingness to skirt rules and take risks when it means helping people effectively. One key theme that recurs is Marc’s impatience with bureaucracy. He prefers results to protocols and makes little secret of his disdain for paper-pushing at headquarters.

Skirting Rules, Breaking Barriers: Turkey, Iraq, and More

Marc’s willingness to bend the rules is perhaps best illustrated in a series of anecdotes from crises at international borders. During an MSF mission, supply trucks loaded with critical medicines are stopped at the Turkish border by an intransigent guard. Here, Marc improvises with audacity: pretending to be a physician, he befriends the guard and fabricates a diagnosis of a fictional disease that threatens, among other things, the guard’s masculinity. The narrative is funny, although unembellished in its narration; Marc describes how he frightens the guard enough that the border blockade is overridden, trucks released, and the medicines delivered to those in need.

The ploy does not stop there. A rival German NGO has eleven trucks stuck at the same crossing; Marc returns for a “follow up” with the guard, who is now very invested in his recovery from the fictitious disease the “Western doctor” has convinced him he is afflicted with. Marc uses his influence to get all the trucks released and parades them through town before handing them over, causing considerable consternation among competitors. The German logistician is sent home soon after, a detail Marc delivers with understated satisfaction. You do not want to be on the wrong side of this dude!

These stories are not about bravado for its own sake. Marc’s actions are always motivated by the need to get things done in environments where strict adherence to protocol would mean failure, which in real terms, is counted in lives lost.

However, there is a childish, almost impish mischievousness that he brings to his lifesaving work. Take, for instance the time when he fabricated an aqueduct building project to bypass Iraqi embargo on sending fuel to the Kurds. Or when he managed to buy two Harleys from a shady businessman for $500, and then he reinvigorated them with new engines, repainted and repurposed them. When he was dismayed to see the astronomical price MSF was paying for their vehicles, he went out into Baghdad, and bought a brand new Toyota truck for a measly $2,500. In the true style of a master logistician, he was able to ship the truck and the Harley back to Paris when he was returning.

In a heartwarming note of candor, Marc relates that MSF’s president at the time, Rony Brauman, greeted Marc’s successes with humor, joking that he should have brought back more motorcycles. Although such exploits would, in another book or perspective, seem reckless or irresponsible, in Marc’s hands, they become evidence of imaginative problem-solving in the service of humanitarian goals.

Motivations: Rules, Pragmatism, and Relentless Action

Throughout the memoir, one guiding principle emerges: when oppressive or inhumane rules exist, bending them to help people is both justifiable and necessary. His worldview is rooted in experience. He has seen firsthand how regulations can prevent aid from reaching the right people, and he has no patience for rules that serve only bureaucratic self-interest.

This practical ethos stands in sharp contrast with MSF’s principle of “temoignage” — bearing witness, speaking up about atrocities as part of the organization’s mission. For Marc, this is often simply a cover for political inaction, an excuse to avoid getting one’s hands dirty. He expresses more admiration for organizations like the Red Cross, which shun the spotlight and avoid media coverage, instead focusing simply on helping people without making pronouncements.

Marc’s restlessness and reluctance to settle or accept restriction are evident throughout. He works around the clock to build a cholera center with seven hundred beds in less than a week. The feat is astounding, but his methods, which frequently short-circuit bureaucracy, make him unpopular among office-based staff. Marc never pretends that humanitarian work is clean, tidy, or free from moral compromise. His accounts are matter of fact, letting the situations speak for themselves.

On Rwanda and International Response

Marc’s skepticism for established authority also extends to figures outside the humanitarian world. One notable example comes from his analysis of General Romeo Dallaire’s role as head of UN peacekeepers in Rwanda during the genocide. Drawing on his own experiences in post-Yugoslavia conflicts, Marc critiques Dallaire’s hesitation and argues that, had military action been taken more decisively, other partners would be forced to join, and many lives could have been saved. This view is blunt and controversial, but it is consistent with Marc’s philosophy: hesitation, indecision, and fear of violating procedure are fatal in true crises.

Diplomatic Irony: Attaché Without Citizenship

In perhaps the most ironic turn of the memoir, Marc is appointed as a humanitarian attaché by the French government, given a role akin to ambassadorial duties, examining the use of aid and strategizing on how the French armed forces could improve their perception amongst humanitarian workers in the Serbian conflict. The twist is not lost on either Marc or the reader; here he is, representing France officially, even though he lacks French residency, let alone deep roots in the country. There is a brief moment of satisfaction, almost levity, at his trajectory from unwanted foster child to corridors of government power. Yet, Marc never dwells too long on such ironies or tries to spin them narratively. He is simply moving forward, always restless, always unwilling to settle or look back.

Literary Style, Structure, and Pacing

The structure and pace of Rebel Without Borders is addictive. The book moves quickly, its narrative comprised of short sentences and tightly written observations. Many events are delivered in staccato succession, rarely pausing to indulge in emotional commentary. The descriptions of horrific situations are blunt, unemotional, and all the more impactful for their restraint.

One criticism, which Marc himself might not disagree with, is that the book lacks a traditional narrative arc. There are many stories — some hilarious, others tragic, many inspiring — but they do not coalesce into a neatly woven plotline. Instead, the memoir is more an accumulation of lived experiences, which, while not conventionally structured, feel true to Marc’s actual life. This approach also means the reader must do some work to identify recurring themes and find patterns in Marc’s character.

Undercurrents: Impatience, Movement, and Family

If there is any unifying thread, it is Marc’s impatience to move forward, refusal to settle, and constant longing for family. Each organization, each group, each mission offers temporary belonging, but none is permanent. When Marc leaves MSF, the moment carries a sense of loss akin to a child once again being pushed from the home. The back-and-forth between finding connection and feeling abandoned is palpable throughout.

Marc’s need to belong is never truly resolved. The undercurrent of loss, abandonment, and yearning for family runs beneath the energetic surface of the memoir. Even as he achieves great things, secures improbable victories, and offers tangible help to thousands, the narrative is always moving. There is no rest, no closure, no grand epiphany, only a ceaseless search for connection.

Abrupt Endings and New Beginnings

The ending of Rebel Without Borders arrives with little warning, much as many episodes begin. Marc finds a measure of peace, or at least a pause, in meeting his daughter from an old relationship he regrets abandoning. The result is not redemption in the literary sense, but a real, imperfect moment suggesting that healing, too, is not easy nor complete for people. He does not offer the reader a sense of closure so much as the assurance that life will go on, and new stories will eventually emerge.

Marc’s future, if the memoir gives any indication, will be as unpredictable and full of action as his past. The suggestion that more stories and possibly another book could follow is not only credible but almost inevitable.

Recommendations: Should You Read It?

Rebel Without Borders is not refined literature in the usual sense, and it hardly delivers a perfectly woven narrative arc. It is a book for readers more interested in authenticity, grit, real-world humanitarianism, and the impossible choices faced when dealing with disasters and conflict. Marc’s story is extraordinary not for its grand gestures, but for its relentless honesty, for its depiction of a man who survives hardship, repeatedly reinvents himself, and often unsettles both friends and institutions.

For anyone curious about what actual humanitarian work entails — including the compromises, the gray areas, the need for rule-bending, and the hard ethical choices — this book will be illuminating. Readers invested in understanding crisis response from the inside, or those drawn to stories of personal transformation, will find Rebel Without Borders rewarding.

If, however, your preference is for stylized prose or literature that follows classic structures, this might not be the ideal read. The real reward in reading this book lies in immersing yourself in Marc Vachon’s world, absorbing the lessons from his journey, and taking away a deeper understanding of what it really means to do humanitarian work on the edge: always moving, always adapting, always seeking connection, and occasionally breaking a few rules along the way.

“Here in prison
rage contained in my breast
I patiently wait
for the clouds to gather
blown by the wind of history.

No one
can stop the rain”

- From “‘Here in Prison” by Agostinho Neto, first President of Angola (1975–1979), PIDE Prison, Luanda, July 1960

I recently found myself with some time on my hands, and so I decided to pick up the slender volume which had been lying around in my bookcase for a while. For me, books often serve as a sanctuary for lived experiences and stories that resonate with the human experience, unveiling narratives that delve into historical landscapes, human resilience, and the indomitable spirit that thrives amidst adversity. “No One Can Stop the Rain: A chronicle of two foreign aid workers during the Angolan civil war,” authored by surgeon Wein Cheng and financial administrator Karin Moorhouse, takes its place within this realm, offering a poignant exploration of their eight-month odyssey as aid workers in Angola.

It is written in an interesting format, with the two authors writing different sets of chapters. Wei writes with the measured grace of a surgeon, while marketing executive Karin writes with flair and flamboyance. The difference in their writing tones is quite overt, and makes for very interesting reading. The book follows a somewhat epistolary tone, with the 66 chapters sounding like missives from Angola. This might actually be reflective of the fact that the book was born from the wavemail updates Wei would send to his friends overseas from Angola.

Karin draws out some of the history of Angola. The almost five-century-long colonial rule by the Portuguese (with a small intermission where the Dutch took over), the impact of the slave trade, and eventual independence in 1975. This hard-earned independence was promptly followed by a civil war between the government forces and the rebel group called UNITA, which was led by a charismatic, yet brutal Jonas Savimbi. In the three decades between independence and Savimbi’s eventual killing in 2002, the fight between the rebel UNITA and government forces reduced Angola to one of the most dangerous places in the world. Karin and Wei produce some statistics showing the ghastly effects this continuous fighting on the Angolan people. Grimly illustrative, these statistics collated by Karin and Wei underscore the deleterious impact of sustained warfare, exemplified starkly by the alarming statistic that one in three children succumbed before reaching their fifth year. As a public health physician, these were numbers I could not reconcile myself to see!

Wei writes with the deftness and precision expected of a surgeon in the operating room. Wei mostly writes about the incredible patients he managed, and while I read on, I marveled at the surgical prowess he must have possessed. He did everything from cesarean sections to burn contracture release, from skin and tissue autografting to amputations… I was particularly struck by the clinical manner in which he described the very disturbing facets of patient care in the midst of conflict. His writing, usually dispassionate and clinical in its precision, however, brought me to the brink of tears when he suddenly changed tack while writing the last chapter where he bids farewell to his team. Eight months, he reasons, is a short period in the terms of a person’s lifetime, but it was long enough to forge friendships and relationships that endured time, distance and communication barriers.

There are a few humorous chapters and narratives — it is not all doom and gloom. Interwoven within this somber tapestry are moments of levity. One particularly light hearted chapter is about the couple’s encounter with a chook (Australian slang for chicken — Karin was born and grew up in Australia), which they wanted to cook, but nobody really had the experience, or the stomach, for actually killing and gutting the bird. The surgeon eventually managed to take over the task and get it done. There are some other narratives peppered in the book, where the couple speak about funny encounters. There are also some hair-raising chapters, such as the one where the couple and their driver are accosted by aggressive policemen looking for a bribe, or the one where a belligerent drunk tried to assault Karin, or the one where a lumbering drunk Angolan started stalking Wei and Karin as they walked home from the hospital (not advisable), until the drunk man stumbled on a pothole and fell face down. These episodes, while seemingly incongruous, provide a holistic portrayal of life within a conflict-stricken landscape, particularly illustrating what happens when a three-decade-long civil war is mixed with plenty of guns and cheap booze.

Although I say that Wei writes with the clinical detachment expected from a surgeon, not for a moment do I mean to imply that his writing does not cover the treacherous fate doled out to his patients. There is a very natural sense of warmth and empathy that suffuses his stories, even when they are told with the staccato precision of a clinical note.

The book is a very interesting read, particularly because both Wei and Karin were poised to have high flying, high paying corporate careers, from which they disengaged for a while, in order to serve with Doctors Without Borders in Angola. This is something that I personally draw some inspiration from. Perhaps, one day, I shall be able to do what these two achieved…

One topic that Karin returns to multiple times is how the uncertain, yet slowed pace of life in Angola allowed her to have many a human moment, which she usually missed in the hustle and bustle of her corporate life in Hong Kong. She speaks about silent elevator rides with colleagues in Hong Kong, and contrasts it with the cheerful greetings she would receive from rank strangers on the streets. She speaks about this in many different settings, and for some reason, I find it a very interesting experience. She managed to find a certain modicum of peace and human connection in a land wracked with decades of civil war, while she could not find that in her developed world life!

Another interesting trait of the book, which adds to the epistolary tone, are the black and white pictures which come at the ending of most chapters. While most of these photos were too blurry or pixelated to make much out of them, I found myself wondering if he had sought written informed consent, or maybe even consent in any shape or form, from the many patients whose pictures he displayed in the book. Ethical considerations aside, these images offer an authentic portrayal of the environment, inviting reflection on the nature of consent and representation. Furthermore, the photographs reveal Wei’s multifaceted talents, extending beyond surgical precision to encompass artistic endeavors such as oil painting.

Overall, this is an arresting read. At less than 300 pages, this is a quick and fluid read. Written lucidly, with a captivating tone which keeps vacillating depending on who is picking up the story thread, this is a wonderfully engaging book to read. At its core, “No One Can Stop the Rain” is an arresting testament to the resilience of the human spirit. Despite its slender built, the book weaves an intricate tapestry of compassion and courage, inviting readers to contemplate the far-reaching impact of even the briefest of encounters. As I navigated the narrative through my own cognitive haze, the book’s allure only grew stronger, serving as a beacon of inspiration that guided me through the labyrinth of words.

Another interesting aspect, one which is quite unexpected in a book about humanitarian health challenges and civil wars, is the fact that there is a certain tenderness and love in the way in which Wei or Karin write about their spouse. This is made amply clear in the way Wei speaks about Karin, especially in the chapter where he gets to welcome her. Wei had joined the program 8 weeks or so ahead of Karin. The angst and longing with which he speaks of Karin in this period is enchanting, to say the least.

I would definitely recommend reading this book if you’re into this kind of reading. It is told in a simple and elegant manner, often talking about distressing things in a matter-of-fact tone which brings a different dimension of the issues to the readers. I needed a couple of days of intense reading to get through it — like I said, I have been trudging through it amidst my brain fog — but it was time well spent. The book’s brevity belies its profound impact, as its pages serve as a conduit for poignant reflections on the indomitable human spirit. While traversing the book’s terrain may demand intense concentration, the effort is unequivocally rewarding.

Pick up a copy!

Heat rises early in the day in Phnom Penh. It drapes the city like a damp, heavy blanket wrapping around cracked balconies and seeping into the narrow lanes crisscrossing across the bustling metropolis. In the balcony of our hotel room, we sip on an exquisitely fragrant cup of coffee, watching the capital slowly wake up: saffron-robed monks shuffle barefoot, their brass bowls tinkling like wind-chimes; a woman in floral pajamas fans the embers of charcoal beneath some kind of honeyed meats, their warm and welcoming aroma wafting slowly across the neighborhood; tuk-tuks or moto-taxis whine through puddles left by the light predawn shower, misting the air with diesel, mud, and the faint tang of fermented fish. We had planned to start the morning some 23 kilometers south of our hotel, at a former longan orchard called Choeung Ek.

Our tuk-tuk driver arrives at half-past eight, surprising us with his punctuality. His fading grey t-shirt proclaims “Life, Liberty and the Pursuit of Tacos” in Comic Sans – an unexpected echo of Americana halfway across the world. We exchange pleasantries while he vigorously cajoles the reluctant engine to restart. In careful English he tells us that he studies sociology at night and ferries travelers around by day. Eventually, the engine coughs to life, settles into an even hum, and we merge into the motley tide of morning traffic. Weaving in and out of traffic, it does not take long for modern storefronts to dissolve into wooden houses, then to flat green meadows bordering our bumpy ride. By now, the sun is rinsing the fields with molten gold.

After another half an hour of driving out of the city, the tuk-tuk driver taps the chassis and points to a rust-red water tower listing over a line of thatched roofs. “Khmer Rouge made people dig canals there,” he says gently. “No machines. Sometimes only with bare hands. My grandfather had scars.” He traces a line across his forearm with a fingertip. I ask whether he has ever stepped inside Choeung Ek. Without looking away from the road he shakes his head. “Long ago,” he mutters, intently looking away from us. “I don’t really have the time, you know.” We know better than to press for more information. We change topics – how about stopping for some green coconuts? “One dollaah!” – his effervescent smile widens, as he careens to a stop next to a lady selling a giant mound of coconuts. It seems one U.S. dollar is the universal price of stuff here! Thirst quenched, we trundle off into the countryside once again.

A sun-bleached plank finally announces, “CHOEUNG EK GENOCIDAL CENTER”. Beyond the ticket booth stretches a tableau so peaceful that for a minute we wonder if the tuk-tuk driver dumped us somewhere else! Mango and palm trees line pebbled pathways, a pond stippled with lotus leaves, dragonflies skimming the water like fragments of stained glass. Birds chirp; a breeze stirs the palm fronds. At the back of my mind, I wonder – this looks exactly like our ancestral farmhouse in Ranaghat, far away in the villages of West Bengal!

The attendant hands me an audio guide; a soft voice in an even accent starts the narration that will hold us spellbound for the next hour or so: “You are standing where there was once a large and beautiful orchard. But, between 1975 and 1979, more than 17,000 prisoners from Tuol Sleng were executed here.” The matter-of-fact tone hits us like a ton of bricks.

The footpath is partly a warped boardwalk, which eventually gives way to a soft path. Ever so often, like a rebellious distributary, a footstep-worn path takes off from the sides of the main walkway. As we walk in, each step makes the planks groan, as though the earth still objects to our trespassing steps. Little wooden stakes and boards protrude from the grass here and there: Mass grave of 450 victims. Mass grave of headless women. The language is bureaucratic, curt; the horror beneath is boundless. Low mounds rise and fall across the clearing like the swells of a becalmed sea; every hump an excavated pit. A faint, sweet-sour odor of fruits, compost, decayed cloth, lingers on in the air. Is that the smell of death, that hangs on decades down the line? Or perhaps it is just in my head.

Humidity clings to my shirt; crickets chirp away in the canopy overhead. Silence settles with such a density that it feels like a slowly building weight building up all around me. This is not the reverent hush of a cathedral, or the studious silence of a museum. It is an unnatural vacuum swallowing life and breath and thought alike. If hell has a sound, it is this silence.

A white stupa looms at the center, its Khmer-style roof knifing into blue sky. Sunlight flashes off glass panels, revealing row upon row of skulls stacked like ivory votive candles. I climb the tiled steps, press my forehead to the cool pane. My breath fogs the glass for a second, before a placard explaining that the structure shelters more than 8,000 crania, sorted by age and sex, swims into my view. An eerie echo of the regime’s mania for counting. I note that some skulls are punctured by nails, others cleft by machetes or the pointed end of some other instrument of death. One shelf holds delicate infant bones; fontanelles were never meant to meet such violence.

Meanwhile, the narrative in my ear is building up the horror story with a practiced nonchalance. Pol Pot’s cadres rarely used bullets; ammunition cost money. Death had to be efficient. And cheap. The audio voice recites this fact in a soothing timber, but my stomach twists. I imagine the last moments of the people whose remains stand before me: their jolting truck ride from the holding cells of Tuol Sleng, the blindfold, the floodlights, the hot taste of fear. Did they believe the lie that they were being relocated to work camps? Or a court to rule on their crimes against the nation? Did any of them dare to hope? I have not been to Auschwitz or Rwanda, but I think evil leaves its mark where it drops roots as deep as it once did here.

A few paces, away a towering trunk is garlanded in red and yellow string bracelets left by visitors who, like me, have no other language for grief. Its bark is dark and scalloped, as if chunks have been gouged out repeatedly. A weather-cracked sign explains, with cruel simplicity: “Killing Tree Against Which Executioners Beat Children.” The audio track does not even falter, as it continues: To save bullets, cadres swung babies by the ankles and smashed them against this tree. Nearby, excavators had uncovered a pit filled with bodies of naked women and infants, most with skulls fractured or massively deformed. A farmer scavenging cassava unearthed the first remains in 1979; tufts of hair, bone splinters, then entire bodies clutched together in the final throes of a painful end.

The tropical air suddenly tastes metallic. I picture mothers screaming; teenagers in black pajamas, with a mask across their faces, hefting a crying infant like a sack of rice; the wet thwack of bone against wood; silence returning almost as quickly as it was broken. I brace a hand on the tree; the bark is warm, almost soft. The tree stood, witness to this inhumanity.

Just meters away, looms another giant palm, pitted by rusty nail holes. Locals call it the “Magic Tree” because during executions loudspeakers were lashed to its branches, blaring revolutionary anthems loud enough to drown human shrieks. A diesel generator chugged beside it, its exhaust mixing with the smell of blood and wet grass - a poisoned petrichor. The condemned died to the sound of ballads praising Angkar, the all-seeing Organization at Pol Pot’s beck and call.

I wander further. Dragonflies dive-bomb puddles; butterflies settle on wild hibiscus, indifferent to the bones beneath and silenced shrieks around us. Every now and then, heavy rains will coax artifacts to the surface; teeth, buttons, scraps of checkered cloth, bones... Staff collect them quietly, rinse them in bowls of water, and place them in glass display boxes. The ground refuses to forget.

As a physician I am trained to hold death at arm’s length: verify the pulse, note the vital signs, sign the certificate, console the family with rehearsed gentleness. Choeung Ek annihilates that distance. Here death is industrial, ideologically engineered, tallied by spreadsheet. I catch myself cataloguing injuries from reflex – basilar skull fracture, subdural hematoma, pulmonary hemorrhage – and then I recoil at the vulgarity of such clinical shorthand. Violence, too, is a pathogen; it spreads on contact, carried by slogans and silence.

I sink onto a bench under a short mango tree with knobby roots, my knees unsteady. An elderly groundskeeper sweeps leaves nearby, each swipe of his broom like a dry whisper across the path. His straw hat hides most of his face, but his eyes are steady, downcast. I say hello; he mutters back a greeting, then something in Khmer that I cannot understand. He goes on sweeping, and the hush of silence swells and fills up the space around us again.

Afternoon light slants like shafts of bronze across the field. I circle the perimeter pond where defiantly pink water-lilies are in full bloom, their beauty refusing to be extinguished. Near the exit a small altar smolders with jasmine-scented incense. I look for a light to ignite a coil, but I find none; so I bow three times, an awkward benediction to strangers I can neither diagnose nor save.

And I whisper a silent promise to remember. Always.

The stupa doors swing shut behind me with a reverential click. The driver has been idling in his tuk-tuk, tinny Khmer rock leaking from his phone speaker, arms folded under this head, like a makeshift pillow, and legs draped lazily over the vehicle’s gilded fender ornaments. The ride back to Phnom Penh is in a different kind of silence; one broken only by the engine and the rumble of returning traffic. The late afternoon traffic throngs around us; yet we ride with Choeung Ek within us, a phantom perched alongside us on the back seat. I scrub my palms against my trousers as if the chill in the Choeng Ek air has seeped under my nails.

Our next stop is Tuol Sleng. Once a high school, now a museum of terror, its courtyards are eerily spotless. Classrooms hold iron bedframes and leg shackles; chalkboards still bear writing scratched by prisoners forced to confess imaginary plots; roughly hewn walls and cells divide the classroom into small, unventilated, dark prison holding cells. Black-and-white mugshots line the walls; teenage boys in checkered shirts, grandmothers clutching ID plaques, toddlers wide-eyed with confusion. Between fourteen and seventeen thousand inmates entered these gates; fewer than twenty walked out alive. Tuol Sleng was the intake valve; Choeung Ek the disposal chute. Even genocide required paperwork.

Night drapes the city in neon and exhaust and an inexhaustible energy to live in the present. Back in our hotel, Bhavna and I tap the dust out of our shoes, and then we scrub our hands until the skin blanches. It is not dirt we are trying to wash away; it is the proximity to “death by design” we just experienced. We ruminate that evening: We study anatomy on cadavers. We learn to cut without emotion. But these skulls are not specimens. They are warnings.

The word that haunts me is Baksbat, “broken courage” (Chhim, 2013). Cambodian psychiatrists use it to denote a trauma distinct from classic PTSD: chronic fear, numbness, a loss of agency that trickles through generations. Public-health workers here treat dengue and tuberculosis, yes, but also a national nervous system charred by atrocity. Trauma is not metaphor; it is epidemiology.

Justice has limped. The Extraordinary Chambers in the Courts of Cambodia began work in 2003. After more than three hundred million dollars and fifteen years, the tribunal secured only three life sentences. Not that their international counterparts had more success - Pol Pot, the principal architect of this extermination, died of old age, surrounded by his loved ones, family, grandchildren, just like any other old and weary traveler. The Khmer Rouge remained the officially recognized U.N. participants a decade after being overthrown by Vietnamese armies. Justice delayed, as the cliche goes, is justice denied.

Survivors call it too little, too late. Yet locals like our tuk-tuk-driving budding sociologist insist that justice is also collective: We remember, so we don’t repeat. Memory, I think, is like herd immunity here.

On our final evening in the city, we drift along the riverfront where the Tonlé Sap meets the Mekong. Vendors roast corn over charcoal; lines of fish to choose from for dinner; children cartwheel in dust that glitters under streetlamps; monks in saffron robes hover over phone screens capturing the violet-gold sunset. Life here is riotous, resilient, insistent. And yet every April, on the Day of Anger, Phnom Penh pauses. Old sorrows surface, like the bones from Choeng Ek’s monsoon mud, and the city chants requiems instead of pop songs.

Just after dusk, we sit in a café, I am gulping down iced coffee thickened with condensed milk and Bhavna sipping pensively on an egg-white coffee. The tuk-tuk driver materializes, holding a glass of coffee of his own, and a piece of paper working out the total amount that we owed him. Bracing for an astronomic number that we would have to haggle down, I am surprised to be met with a very reasonable figure. As we hand over sundry coins and dollar notes, “What did you learn?” he asks. I search for eloquence, for a thesis on vigilance, on how ordinary men become executioners, how hate mutates like a virus; but the words tangle. “I’m still processing,” I confess. He sips his tea, nods slowly. “Me too,” he says, though he lives the generational trauma every day.

We part at the airport. As the plane lifts through monsoon haze, Choeung Ek shrinks to a green smudge on the outskirts of the capital. I cannot even figure out which way it lies… Yet the field remains inside me, vibrating like a tuning fork whenever the word genocide grazes a headline. Bones keep surfacing after every heavy rain; the ground refuses forgetfulness. The dead are always speaking. The question, is whether we will listen.

If you choose to listen, begin with Elizabeth Becker’s When the War Was Over, Philip Short’s Pol Pot, and David Chandler’s Voices from S-21. Explore the Yale Cambodian Genocide Program’s digital archives; sit with the survivor testimonies. Bones, however eloquent, cannot describe what ears heard on nights when loudspeakers drowned human pleas.

We say never again, as if repetition were impossible. Yet genocides recur. In Rwanda, Darfur, Myanmar, Gaza. Pathogens evolve; and so does hate. The only inoculation is vigilance: to look, to name, to remember until silence itself shouts down the next rallying anthem. May we never tire of honoring the bones that surface. May we heed them before the earth is forced to speak once more.

Each sense sharpens on those ribbon-thin countryside roads. The petrichor, the ion-charged perfume of geosmin, settles into the cabin. The tires hiss across the occasional puddle, the doppler whoosh of the lone oncoming car recedes, and a wash of darkness, and silence, returns. The dim glow from the dials on the dashboard casts a warm penumbral hue around me. The steady rhythm of the wipers marks a metronome for me to breathe to. With the phone on airplane mode and no voices on the radio, the mind finds the rarest of 21^st century luxuries: spacious silence.

Out here, etiquette simplifies to a brief dip of high beams, an automotive bow acknowledging a fellow traveler. Social neuroscientists call this the minimal social cue (Rigdon et al., 2009): a micro-gesture that signals trust and reduces perceived isolation, without infringing on my carefully curated isle of solitude. On an unlit stretch of asphalt, that fleeting flash feels as intimate as a handshake in daylight. This isn't just a romantic notion; it's a deeply restorative experience, one that science increasingly suggests can offer a powerful pathway to cognitive renewal and creative insight.

In our hyper-connected age, the dangers of constant digital engagement are well-documented. Excessive screen time isn’t just a nuisance; it’s linked to increased stress, anxiety, depression, sleep disturbances, and even physical health issues like obesity and heart disease. Our brains are simply overwhelmed by the “constant barrage of online information”, hindering our ability to concentrate, make decisions, and think creatively.

The act of unplugging offers a vital counter-narrative. It allows the mind and body to truly recharge, leading to improved mental health, overall well-being, and a better quality of life. When we step away from our devices, our brains get a much-needed rest and reset, which in turn sharpens our focus, decision-making, and creative faculties.

A solitary drive, particularly on less-trafficked roads, offers a unique, almost effortless form of this disconnection. Unlike a conscious decision to put down your phone, which requires willpower, driving demands your attention be elsewhere for safety. This enforced shift away from digital distractions transforms a routine activity into a therapeutic tool. It’s a built-in “digital detox” that can be especially valuable for people like me, who struggle to self-regulate their screen time. Beyond just digital devices, this kind of drive offers a broader disconnection from the relentless demands of the external world. With minimal traffic and winding single roads, the usual cognitive load of urban navigation melts away, freeing up mental space for introspection and reducing stress. When external demands quiet, our brains can shift from a “habitually reactive” mode to a more “skillfully responsive” one, fostering a deeper meditative state and greater clarity.

The feeling of a night drive as a very meditative experience resonates deeply with psychological concepts of mindfulness and flow states. Mindfulness, at its core, is about being fully present and aware of the moment, without judgment. While learning to drive demands intense focus, experienced drivers often operate on autopilot for routine tasks, freeing up cognitive resources for a different kind of awareness. This allows for a conscious engagement with the surroundings, the feeling of the steering wheel in your hand, the sounds of the tires on wet asphalt, the shifting glow of headlights, transforming driving into an active meditation.

This purposive act of mindfulness can also quiet the default mode network (DMN), the brain network associated with mind-wandering and rumination, leading to less distraction and enhanced self-awareness. This suggests that the meditative quality of a drive isn’t just a feeling; it’s a verifiable neurobiological shift. Baird and colleagues demonstrated that performing an undemanding task, one that leaves attentional bandwidth for mind-wandering, supercharges the “incubation” phase of problem-solving (Baird et al., 2012). Driving quiet back-roads at night fits their paradigm perfectly: the hands and eyes stay busy enough to anchor awareness; the prefrontal cortex loosens its executive grip, allowing the default-mode network to braid disparate memories into fresh insight.

The idea that driving can spark creativity might seem counterintuitive, but it builds on established research about physical activity and cognitive function. Take walking, for instance. An oft-quoted study by Oppezzo and Schwartz, from Stanford University study found that walking boosts creative ideation; it specifically improves divergent thinking by about 60% compared to sitting (Oppezzo & Schwartz, 2014). This benefit is thought to come from our ability to “open up the free flow of ideas” during a stroll, and relax the suppression of associative memories. Even a short 10-minute walk can significantly improve memory and attention (Mualem et al., 2018).

A 2025 meta-analysis of fMRI studies noted overlapping activation in the left inferior frontal junction and pre-SMA during both “creative exploration” and spatial way-finding, an elegant neural hint that navigating highways and idea spaces may share circuitry (Liu et al., 2025). Add the rhythmic sensory diet of rain and wipers, sprinkle in dopamine release linked to mild novelty, and you have an almost laboratory-grade recipe for divergent thinking. Folk wisdom calls it highway hypnosis; cognitive science sees a productive trance.

Low Cognitive Load and Mind-Wandering: When driving becomes routine, especially on quiet roads, the brain shifts into a more automatic “System 1” mode, reducing the cognitive load on the prefrontal cortex. This reduced load allows for spontaneous “mind-wandering”, a state empirically linked to enhanced creativity and problem-solving (Simor et al., 2025). Unlike high-stress tasks where mind-wandering can be detrimental, low-effort activities allow for beneficial, unconscious learning and ideation, almost like “sleep-like neural activity”. For me, the quiet night drive exists in this sweet spot, providing just enough engagement to prevent boredom, but not so much as to demand continuous, high-level processing, allowing the mind to wander productively.

Nature Exposure: Driving through “forested areas”, as I was doing last night, provides direct exposure to nature. Attention Restoration Theory (ART) suggests that natural environments, with their “intriguing stimuli”, gently capture our attention, allowing our “directed-attention abilities” to replenish (Berman et al., 2008). This mental restoration primes the brain for creative insight and deeper thought.

Repetitive Motion: The consistent, rhythmic motion of driving, much like walking, can be a form of repetitive task. Studies suggest that routine tasks, by minimizing decision fatigue and fostering habit, free up mental energy for creative problem-solving and innovative thinking. The brain uses less processing power for these automated actions, making more mental energy available for new ideas (Chae & Park, 2023). Perhaps this is why I enjoy listening to the same song or musical piece on an interminable loop when working – it does drive Bhavna crazy, but it seems to be an effective strategy to maintain flow state for me. While driving is a complex task requiring integrated sensory, motor, and cognitive abilities like attention, memory, and executive functions, when these functions are not overwhelmed by traffic or unfamiliarity, they can create an optimal state for the mind to wander productively (Tapia et al., 2025).

This profound experience of a solitary drive isn’t something new; it echoes through a rich cultural tapestry of introspection and discovery. In literature, the road trip is a powerful motif for self-discovery and freedom. Jack Kerouac’s On the Road famously captures the Beat Generation’s search for meaning through frenetic cross-country journeys, embodying a spirit of unbridled movement and countercultural expression. John Steinbeck’s Travels with Charley offers a more mature, reflective journey across America with his poodle, exploring themes of change, isolation, and his personal quest to understand a rapidly evolving nation. That same alchemy of wheels and wonder reverberates in Ernesto Che Guevara’s posthumously published memoir The Motorcycle Diaries, which chronicles the 23-year-old medical student’s ride across Latin America. Each dusty mile shifts Guevara’s gaze from personal adventure to the inequalities that would forge his revolutionary consciousness, proving how a road can reroute an entire life trajectory. Half a century later, neurologist Oliver Sacks would find similar liberation astride his BMW. In his memoir On the Move: A Life, whose opening pages thrum with the “restless energy” of motorcycle travel, Sacks describes long solo rides across the American West that catalyzed clinical insights and self-reflection alike, showing that even a scientist’s most rigorous thinking can be sparked by the steady pulse of an engine. And of course, the somewhat shocking details of the proverbial journey from his orthodox Jewish family to discovering and exploring his sexual identity.

And what would a drive be without its soundtrack?

Music often amplifies the emotional and introspective qualities of solitary journeys. I started the ignition with Mohiner Ghoraguli’s “Prithibi Ta Naki”, a looping folk-rock reverie that settles your breathing into the same unhurried cadence as the road. As the winding bucolic roads grew more intricate, and forested underbrush started long punctuations between a house or a farm, the mood deepened as Fossils’ “Ekla Ghor” took over; Rupam Islam’s raw vocals turned the cabin into a personal confessional booth for me. The drizzle outside called up Cactus’ “Brishti,” its bluesy guitar licking at the rain-spattered glass. The mood shifted with Lakkhichhara’s “Jibon Chaichhe Aaro Beshi” and “Kemon achho shohor” a head-banger that made me feel like rolling the windows down to feel the night air on my face. I then eased into introspection on Anupam Roy’s “Ekbar Bol,” where soft acoustics encouraged a quiet hum-along as mile markers blur. And once the mood and rhythm had slowed down, I lapsed back into my Anjan Dutta mood – one after the next, the music apps churned out his ode to monsoon – “Ami Brishti Dekhechhi” and the more mischievous “Ekdin Brishtite Bikele”.

The first notes of classic rock started to float in as I left the last streetlamp behind: Nirvana’s unplugged rendition of Lead Belly’s “Where Did You Sleep Last Night.” Stripped of distortion, Kurt Cobain’s voice sounded even more feral, every rasp catching in the pine-scented air that seeped through the cracked window. Lead Belly’s old Appalachian lament had always felt like the night itself, dark, unresolved, and in Cobain’s hands the song became a raw confession. Each time he exhaled that final, vein-bursting scream, the road ahead seemed to pull tighter into shadow, as if asking me the same question: Where are you heading, and what are you running from?

The track faded into the steady hum of tires, and the shuffle served up Bruce Springsteen’s “Streets of Philadelphia.” I was nowhere near Broad Street, just skirting the outskirts of Baltimore, but the Boss’s hushed vocal fit the deserted Maryland back-roads better than any map. Springsteen sings about walking alone with “a bruised and broken frame,” and in that moment the ghost-lit warehouses and silent rowhouses I breezed past felt like distant cousins to the song’s empty avenues. His gentle drum loop echoed the thump of my own pulse: a reminder that even in motion we carry the city’s quiet sorrow with us.

Two hours slipped by like a single breath, and the playlist sensed I was ready to come up for air. The ringing intro of Tom Petty and the Heartbreakers’ “Learning to Fly” lifted the cabin’s mood the way sunrise lifts fog. Petty’s laid-back drawl, “I’m learning to fly, but I ain’t got wings”, turned the damp tarmac into a runway, the dashboard lights into cockpit instruments. The rain eased to a mist. Headlights of an oncoming car dipped in wordless camaraderie. Suddenly the night felt less like an escape and more like permission: permission to drift, to dream, to believe that a couple of hours beyond the drudgery might be enough runway to get airborne again.

When the chorus hit its third repeat, I realized my shoulders had dropped, my jaw unclenched. Anjan’s intoxication, Rupam’s ragged roars, Lakkhichhara’s restless exuberance, Cobain’s wail, Springsteen’s murmuring drawl, Petty’s open-sky promise: distinct voices threaded the same needle – the road as confessional, as companion, as launchpad. I turned the volume just high enough to feel the kick drum in my ribs, eased into the final bend, and let the song carry me the rest of the way home.

The drizzle thins, and the steam playing hide and seek with my headlights disappear. What was supposed to be a few minutes’ drive back from the gym had transformed into a 100-mile detour. Yet, what seemed like a moment’s pause was broken when I realized that I was pulling into our apartment’s parking lot. Long after reaching home, the after-glow of that meditative drive lingered.

So, the next time deadlines loom and the inbox pings like a faulty smoke alarm, consider trading in your blue screen-light for glowing-red taillights. A slow cruise through forested lanes may be the freshest idea-board your brain can find. Fill the tank, silence the phone, and steer toward the kind of darkness that lets new constellations, cognitive and celestial, come into view. You might return with nothing more than tranquillity… or the opening paragraph of your next big idea.

Either way, the road will have given you something the daily grind rarely does: room to wander.

References:

Baird, B., Smallwood, J., Mrazek, M. D., Kam, J. W. Y., Franklin, M. S., & Schooler, J. W. (2012). Inspired by distraction: Mind wandering facilitates creative incubation. Psychological Science, 23(10), 1117–1122. https://doi.org/10.1177/0956797612446024

Berman, M. G., Jonides, J., & Kaplan, S. (2008). The Cognitive Benefits of Interacting With Nature. Psychological Science, 19(12), 1207–1212. https://doi.org/10.1111/j.1467-9280.2008.02225.x

Chae, H., & Park, J. (2023). The Effects of Routinization on Radical and Incremental Creativity: The Mediating Role of Mental Workloads. International Journal of Environmental Research and Public Health, 20(4), Article 4. https://doi.org/10.3390/ijerph20043160

Liu, Y., Wang, M., & Rao, H. (2025). Common neural activations of creativity and exploration: A meta-analysis of task-based fMRI studies. Neuroscience & Biobehavioral Reviews, 174, 106158. https://doi.org/10.1016/j.neubiorev.2025.106158

Mualem, R., Leisman, G., Zbedat, Y., Ganem, S., Mualem, O., Amaria, M., Kozle, A., Khayat-Moughrabi, S., & Ornai, A. (2018). The Effect of Movement on Cognitive Performance. Frontiers in Public Health, 6. https://doi.org/10.3389/fpubh.2018.00100

Oppezzo, M., & Schwartz, D. L. (2014). Give your ideas some legs: The positive effect of walking on creative thinking. Journal of Experimental Psychology: Learning, Memory, and Cognition, 40(4), 1142–1152. https://doi.org/10.1037/a0036577

Rigdon, M., Ishii, K., Watabe, M., & Kitayama, S. (2009). Minimal social cues in the dictator game. Journal of Economic Psychology, 30(3), 358–367. https://doi.org/10.1016/j.joep.2009.02.002

Simor, P., Vékony, T., Farkas, B. C., Szalárdy, O., Bogdány, T., Brezóczki, B., Csifcsák, G., & Németh, D. (2025). Mind Wandering during Implicit Learning Is Associated with Increased Periodic EEG Activity and Improved Extraction of Hidden Probabilistic Patterns. Journal of Neuroscience, 45(19). https://doi.org/10.1523/JNEUROSCI.1421-24.2025

Tapia, J. L., Sánchez-Borda, D., & Duñabeitia, J. A. (2025). The effects of cognitive training on driving performance. Cognitive Processing, 26(1), 219–230. https://doi.org/10.1007/s10339-024-01245-6

The sun beats down on the cracked earth. Summers in Purulia can be unforgiving. Eddies of dust swirl in the warm air as the afternoon heat wave ripples through this bucolic corner of rural West Bengal. Inside a small, mud-walled hut, a family watches their most valuable possession – a dairy cow – struggle to breathe. Her fever is high, her milk has dried up, she hasn't eaten in over four days. What began as a small limp that the family ignored for a few days has rapidly cascaded into a potential catastrophe. For this family, she is not just an animal; she is their bank account, their children's source of nutrition, their entire net worth walking on four legs. Perhaps I am being disrespectful referring to the beloved animal in such material terms, because for most of the households in this village, their livestock and poultry are like extensions of their natural, human families. It is truly an interdependent way of life where humans and animals live together through precarious climate – both economic and meteorological.

The nearest government veterinarian is a full day's journey away, an impossible distance over rutted roads. There is no guarantee having hauled the sick animal all the way to the town clinic, that they would be able to access the healthcare services she needs. Most services in government clinics are either free or come for a nominal fee – the crippling expense comes in when the animal needs to be transported over undulating terrains and potholed roads. It is not an easy affair to haul a thousand-pound animal over miles of unforgiving roads.

A single phone call brings a different kind of help. He arrives on a sputtering motorbike, a worn bag slung over his shoulder. He is not a veterinarian, not officially anyway. In this part of India, he is known as the Private Doctor, a friend to the family when they really need one. In other parts of the world, he might be called a para-vet or a Community Animal Health Worker (CAHW) (Sudhinaraset et al., 2013). He is a neighbor, a familiar face. He listens patiently, nods with an air of confidence, and rummages through his bag. He pulls out a syringe and a small, unlabeled bottle of liquid. A quick injection, a few words of assurance, and a small fee is exchanged. For now, hope is restored. The private doctor leaves the family a couple of pills, several words of reassurance and asks them to give him a call and update him after 24 hours.

He swings onto his trusted steed and pumps the kick-starter – once, twice, and a third time, before the geriatric motorbike sputters to life, belching thick black smoke; phone pressed to his ear, he rattles off toward his next call of care.

This scene, or one very much like it, plays out millions of times every day across the globe. In the vast landscapes of Asia, Africa, and Latin America, where over 1.5 billion people rely on livestock to survive, these informal providers are the beating heart of animal healthcare (World Organisation for Animal Health, 2019). They are the indispensable frontline responders in a system riddled with what experts call “Manpower and Service Delivery Gaps” (Bugeza et al., 2017). They step into the void left by formal veterinary services, offering a lifeline to the world's most vulnerable farmers. They are accessible, affordable, and, most importantly, trusted (Sudhinaraset et al., 2013). But herein lies a dangerous paradox, a dilemma hidden within the dusty contents of the animal friend’s bag. His "magic potions" are often a cocktail of antibiotics, steroids and other modern medicines, acquired from unregulated street-side stalls, with little knowledge of the right drug, the right dose, or the right disease (College of Veterinary Medicine & The Ohio State University, 2025). His well-intentioned actions, repeated millions of times over, are inadvertently fueling a silent, creeping pandemic: antimicrobial resistance (AMR) (Liu et al., 2023). He is, at once, a local savior and a global threat.

This is the story of that paradox.

It is an argument that we cannot simply ignore the informal providers or just wish him away. He is too essential. Instead, we must embark on a journey of transformation. By recognizing, training, and welcoming these informal providers into the official family of animal healthcare, we can turn them from unintentional vectors of risk into our most powerful allies in the fight for a healthier planet. This is not just a story about vets and cows. It's a story about safeguarding our food, our economies, and our own health from the interconnected threats of disease and drug resistance, a concept known as One Health (University of Minnesota, 2023; World Health Organization, 2021). The animal friend stands at a crossroads. By helping him choose the right path, we can help secure a safer future for us all.

1. The Double-Edged Sword: The World of the Para-Vet

To understand the para-vet's dilemma, we must first walk a mile in his shoes. We must see the world as he sees it: a world of desperate need, of deep community bonds, and of dangerous, hidden, fallacious costs. His existence is not an accident; it is a direct consequence of a system that has failed the very people it is meant to serve… and that he has managed to monetize and leverage to help himself and the community he shares space with.

1.1. The Great Veterinary Desert

Imagine a map of the world’s animal health services. In the cities and wealthy farming belts, you would see bright clusters of light, the clinics of highly trained, well-equipped veterinarians (Rondeau, 2023). But as you move out into the remote rural and pastoral lands, those lights flicker and die out, leaving a vast and dark “veterinary desert”. This is the world where the majority of the planet's smallholder farmers live, and it is a desert of our own making.

Beginning in the 1980s, a wave of economic reforms saw many governments cut back on public services, including veterinary care, hoping the private sector would fill the gap (Rondeau, 2023). It was a gamble that didn't pay off. Private vets, needing to make a living, naturally set up shop where the money was: serving large commercial farms or wealthy pet owners in the cities. The economics of serving a poor farmer with two goats and a cow in a village a hundred miles from the nearest paved road simply didn't add up (Bugeza et al., 2017). The state vanished, but the private market never arrived. Into this vacuum stepped the informal provider. He was a local resident, willing to travel by foot or motorbike, ready to accept a small payment or even barter for his services. He became the only option. Studies show that in some regions, these para-vets handle up to 90% of all animal health needs (Sudhinaraset et al., 2013). They are not a fringe element; they are the system.

This reality challenges how conventional health systems approach teaches us to think about the problem. Any plan to simply ban these providers is not only destined to fail, but it would also be cruel. It would be like bulldozing a settlement’s only well without providing a new source of water. You wouldn't eliminate the problem; you would only deepen the crisis. The goal cannot be eradication. It must be transformation.

1.2. The Currency of Trust

If the veterinary desert explains why para-vets exist, the secret to their success, the reason a farmer calls them instead of waiting for a government official, can be summed up in one word: trust.

Formal systems, with their bureaucratic forms, unfamiliar jargon, and nine-to-five city office hours, often inspire more suspicion than confidence (Bugeza et al., 2017). Trust, researchers have found, isn't just about a fancy degree. It's built on empathy, on feeling heard, on a provider who shows genuine concern and speaks your language (PetDesk, 2025). This is the para-vet and informal providers’ home turf. He is a member of the community (Scholz & Trede, 2023). He understands the subtle cultural cues, knows the family’s history, and is available at midnight when a cow is having a difficult birth (Maiti et al., 2011). He doesn't just treat the animal; he reassures the owner. This deep, relational bond is a ‘trust dividend’ that formal systems struggle to earn. An evaluation of the Prani Bandhu program in West Bengal found that while farmers knew these men weren't official vets, they valued them immensely for one simple reason: they always showed up (Maiti et al., 2011).

This insight is a game-changer. It tells us that any attempt to “professionalize” these providers that focuses only on textbooks and technical skills is doomed. We would be creating a cadre of junior vets who are technically better but have lost the very “superpower” – their community connection – that made them effective without their technical training. The World Organisation for Animal Health (WOAH) wisely recognizes this, including a whole section on “Engaging with the Community” in its training guidelines for these workers (World Organisation for Animal Health, 2024). To succeed, we must build on their trust, not replace it.

1.3. The Invisible Plague in the Bag

Now we must look inside the para-vet’s worn leather bag, for it contains both the cure and the curse. The same accessibility that makes him a hero also makes him a major source of a global health nightmare.

Imagine every antibiotic is a unique key, designed to unlock and disable a specific type of bacteria. Now imagine that every time we use a key incorrectly, using the wrong one for the wrong lock, or only turning it halfway, the lock “learns”. It changes its internal tumblers, ever so slightly. Soon, the key no longer works. This is antimicrobial resistance (AMR) in a nutshell. And the para-vet, with his bag of assorted, often mysterious “keys”, is unintentionally teaching the world’s deadliest germs how to change their locks.

This happens in three ways. First, without proper training or diagnostic tools, his choice of drug is often a blind guess (College of Veterinary Medicine & The Ohio State University, 2025). He might use a powerful, broad-spectrum antibiotic for a simple viral infection where it has no effect, like using a master key on a door that's already open. Second, he gets his drugs from a chaotic, unregulated market of back-alley shops and itinerant salesmen (Jaime et al., 2022). These drugs can include antibiotics that are deemed “critically important” for saving human lives, and they are sold to him without a prescription like candy (Dione et al., 2021). Third, and perhaps most terrifyingly, these drugs are often fake. They may be expired, stored in the blistering sun, or deliberately counterfeited with chalk dust instead of active ingredients (Lemma et al., 2025). When a sick animal gets a dose of this junk medicine, it’s like turning that antibiotic key only halfway. The weakest bacteria are killed, but the strongest survive. These “superbugs” then multiply, now armed with a genetic memory of how to defeat our best medicines (Hufnagel, 2020).

This isn’t just a problem for cows and goats. Animal agriculture is a massive factory for creating resistant germs (Liu et al., 2023). These superbugs travel from the farm to our families. They contaminate meat, milk, and eggs. They seep into the soil and water from animal manure. They pass directly to farmers through simple contact. Suddenly, a resistance gene that was born in a chicken shed in a remote village can end up in a hospital in a major city, rendering our last-resort antibiotics useless against a child’s bloodstream infection. This isn’t a hypothetical threat anymore. AMR is already killing over a million people a year, a silent pandemic that threatens to send modern medicine back to the dark ages (Ballash et al., 2024; Naghavi et al., 2024). The para-vet, the animal friend on his motorbike, stands at the very epicenter of this crisis. He is the gatekeeper. The final decision to use an antibiotic on the farm is his. To win the war against superbugs, we don’t just need new laws in capital cities; we need to win the hearts and minds of the men and women on the front lines. We need to transform them from gatekeepers into guardians.

2. A Framework for Transformation: Forging a New Kind of Hero

How do we turn a well-meaning but dangerous amateur into a trained, accountable professional? It can’t be done with workshops or pamphlets. It requires a complete overhaul, a hero’s journey of transformation built on three powerful pillars: giving them a badge, equipping them the right decision-making heuristics, and inviting them to join the league of heroes.

2.1. Pillar 1: A Badge and a Rulebook – Formal Recognition

The first step is to bring the para-vet out of the shadows. For too long, they have operated in a legal grey zone, officially ignored, unofficially tolerated (Rondeau, 2023). This has to end. They need a badge, a formal, legal status that recognizes their existence and their importance. This means rewriting the old laws, the Veterinary Council of India’s standards and acts, to create an official space for them.

Countries in West Africa have already started drawing these lines, creating legal roles for para-professionals (Luseba, 2015). The American Veterinary Medical Association provides a model “rulebook” that can be adapted, helping to standardize titles and responsibilities (American Veterinary Medical Association, 2025). This legal recognition is the foundation for everything else. It creates clear lines of authority, establishes accountability, and gives the informal para-vet a sense of professional pride and purpose (Bugeza et al., 2017). But a badge alone is not enough. The cautionary tale of Cambodia shows us why. The country gave official status to thousands of Village Animal Health Workers (VAHWs), but years later, nearly half of them were inactive (Veterinaires Sans Frontieres, 2024). A badge is just a license to operate; it doesn’t pay the bills or keep your skills sharp. India’s Prani Bandhu program faces similar struggles, with endless debates about what they should and shouldn't be allowed to do, even with government backing (Barbaruah, 2016). The law must be the start of the journey, not the end. It must be backed up by real enforcement and a system that allows these newly minted officers to actually succeed (Willems, 2007).

2.2. Pillar 2: The Core Competencies of Modern Medicine

For decades, training for para-vets has been a chaotic mess of short, informal workshops run by different aid groups, each with its own ideas of what is important, and what is not (Rondeau, 2023). The result is a workforce with wildly inconsistent skills and dangerous gaps in knowledge. It’s time to throw out the scattered notes and give everyone the same, official spellbook. Fortunately, that spellbook has already been written. The World Organisation for Animal Health (WOAH) has created a global gold standard: the Competency and Curriculum Guidelines for Community Animal Health Workers (World Organisation for Animal Health, 2024). This isn’t just another training manual. It's a harmonized, internationally approved blueprint that countries can use to build a truly professional class of providers. The WOAH guidelines are a masterclass in what a modern para-vet needs to know. They go far beyond just jabbing needles into animals. They teach:

· The Rules of the Game (Module 1): Understanding their legal role, their code of ethics, and, crucially, knowing their limits.

· Reading the Signs (Modules 2 & 5): The fundamental skill of telling a healthy animal from a sick one and recognizing the tell-tale signs of common diseases.

· Mastering the Skills (Module 7): This is the heart of antimicrobial stewardship. It’s where they learn about the different kinds of medicines, why using quality drugs matters, and the terrible risks of AMR. It’s where they learn not to use a sledgehammer to crack a nut.

· The Power of Prevention (Module 8): Shifting the mindset from constantly fighting fires (treating sick animals) to building fireproof houses (preventing disease through vaccination and clean practices).

· The Art of Persuasion (Module 10): Honing the “soft skills” of communication that allow them to build trust and convince a skeptical farmer to follow their advice.

· Making a Living (Module 11): The practical business skills needed to run a sustainable service, ensuring they can support their own families while serving the community.

This is how you fight AMR at its source. You don't just tell them “AMR is bad.” You teach them how to be better diagnosticians, so they don't need to guess with a broad-spectrum antibiotic. You teach them about the dangers of counterfeit drugs. You give them the communication skills to explain to a farmer why they must wait a week before drinking milk from a treated cow. This is strategic, targeted, and transformative.

Table 1: The Para-Vet's New Toolkit for Fighting Superbugs (Adapted from WOAH CAHW Guidelines)

2.3. Pillar 3: Joining the League of Heroes – Systemic Integration

A trained para-vet with a badge is a powerful asset. But a trained para-vet who is a formal part of a national team is a superhero. The final pillar of transformation is integration: welcoming these providers into the official animal health system, not leaving them to fend for themselves. This means creating a clear chain of command. Every para-vet should have a mentor, a registered veterinarian or a senior professional they can call for advice, who checks their work, and who holds them accountable. This mentorship is a lifeline, providing technical backup and continuous on-the-job learning. It also means building a functional referral system. When a para-vet faces a problem too big for them to handle, there must be a clear, simple, and affordable way to pass the case up the chain to a full veterinarian. This ensures the animal gets the best possible care and builds public confidence in the entire system.

Most excitingly, integration turns the para-vet into a public health sentinel. With their ears to the ground in thousands of remote villages, they are the perfect early warning system for disease outbreaks. Imagine a network of 10,000 trained para-vets all reporting into a central system. They could spot the first signs of a new zoonotic flu, a potential foot-and-mouth disease outbreak, or a new anthropozoonotic threat before it explodes into a regional crisis. In West Africa, trained CAHWs are already doing this, reporting thousands of disease events and helping to control devastating plagues like Peste des Petits Ruminants (PPR) (Sow et al., 2023).

How can a country map this out? WOAH provides another powerful tool: the Performance of Veterinary Services (PVS) Pathway (World Organisation for Animal Health, 2025a). It's like a comprehensive physical for a country’s entire animal health system. It helps leaders identify their weaknesses, particularly in their workforce, and create a strategic plan to integrate para-vets effectively (World Organisation for Animal Health, 2025b). It provides the blueprint for building a modern, multi-tiered animal health army. Finally, integration must be digital. In the 21^st century, every recognized provider, from the top vet to the village para-vet, should be in a national database. This allows officials to instantly verify credentials, track drug distribution, and manage outbreak responses with speed and precision. By bringing the para-vet into the system, they cease to be just a guy on a motorbike; they become a vital node in a national network of health and security.

3. Tales from the Field: Stories of Triumph and Trouble

The three-pillar framework of recognition, education, and integration sounds great in theory. But the real world is messy. The stories of para-vet programs from around the globe are not simple fables of success or failure. They are complex tales of good intentions, unexpected obstacles, and hard-won lessons that can guide us forward.

3.1. The Case of the Confused Mission: India's “Prani Bandhu”

In the Indian state of West Bengal, the government launched an ambitious program called Prani Bandhu (literally “Friends of Animals”). The idea was to train unemployed young people to provide doorstep services to farmers, creating jobs and improving livestock productivity through a Public-Private Partnership (Maiti et al., 2011).

On the surface, it seems to be working well. The Prani Bandhus were deployed, and farmers were happy to have someone, anyone, they could call in an emergency. But dig a little deeper, and the story gets complicated. The government's top priority was breeding. They trained the

Prani Bandhus primarily to perform artificial insemination (AI) to create more productive crossbred cows. But what did the farmers really want? They wanted someone to treat their sick animals. This created a fundamental conflict. The providers were measured on their AI targets, but their customers wanted them to be doctors. The result? Everyone was just “somewhat satisfied.” Performance was rated as “average” across the board. Worse, because their role was so blurry, it opened the door to risk. They were performing a technical task (AI) but were also being pressured to act as vets, often using drugs without proper training or supervision, raising all the alarms about fueling AMR.

The moral of the Prani Bandhu story is that you can’t push a solution, no matter how well-intentioned, from the top down. The mission must be aligned with the community's actual needs. Otherwise, you end up with a confused hero, trying to do one job while the world is screaming at him to do another.

3.2. Lone Rangers of the Savannah: Africa’s CAHWs

Across the vast, arid landscapes of Sub-Saharan Africa, a different story unfolds. Here, the heroes are the Community Animal Health Workers (CAHWs), often trained by international aid groups to serve the most remote and conflict-affected pastoralist communities. And they are true heroes. Study after study from Kenya, Uganda, Ethiopia, and even war-torn South Sudan shows that CAHWs are deeply valued and incredibly effective (Leyland et al., 2014). They save livestock, which are the lifeblood of these communities, and in doing so, they protect families from starvation (Okoth, 2024). In many of these places, they are the only sliver of hope in the veterinary desert.

But these heroes are fighting with one hand tied behind their backs. They are lone rangers, operating without official support. Most have no legal status, no badge to prove their legitimacy. They struggle to find quality medicines, often forced to buy from the same shady dealers they are trying to replace (Jaime et al., 2022). And their work is precarious, often dependent on the whims of donor funding. When a project ends, their support system, their supply of fresh medicine kits, their small stipend vanish overnight, leaving them and their communities stranded once again (Leyland et al., 2014).

The lesson from Africa is powerful: a hero is only as good as his sidekick. You can train the most skilled provider in the world, but if you send him into the wilderness without the shield of technical expertise, with no access to effective essential diagnostics and medicines, lacking a reliable supply line, or a way to make a sustainable living, he will eventually fail. The focus must shift from simply training heroes to building a system that supports them.

3.3. The Forgotten Army: Cambodia's VAHWs

Cambodia’s story offers the final, crucial piece of the puzzle. Here, the government did almost everything right, at least on paper. They created a formal system of Village Animal Health Workers (VAHWs), gave them legal recognition, and scaled up the program to cover nearly every village in the country: a registered army of over 11,000 providers (Veterinaires Sans Frontieres, 2024). It was a model of official commitment.

But a few years ago, a shocking report emerged: only 47% of this great army was still active. The rest had simply faded away. Why? The government had issued the badges and provided the initial training, but then the support stopped. The VAHWs complained that their skills were getting rusty without regular refresher courses. They couldn't compete with the informal drug sellers because they had no reliable access to affordable, high-quality medicines. They felt forgotten and unappreciated. The Cambodian case is perhaps the most sobering lesson of all. It proves that even legal recognition and massive scale are not enough. Professionalization is not a one-time event; it is a continuous process. An army, no matter how large, is useless if it runs out of ammunition and its commanders forget it exists. The solution, some have found, is for the VAHWs to band together, forming cooperatives to buy supplies in bulk and advocate for themselves. They are learning that if the system won't support them, they must support each other.

Table 2: A Tale of Three Heroes: Comparing Para-Vet Models

4. The Path Forward: Choosing Our Champions

The story of the informal veterinary provider is the story of a problem that is also a solution. We stand at a global crossroads. Down one path lies the status quo: a world where millions of well-meaning but undertrained individuals continue to be a primary engine of antimicrobial resistance, the silent pandemic that threatens us all. Down the other path lies transformation: a world where we invest in these individuals, train them, support them, and turn them into an army of antimicrobial stewards.

The choice creates two very different futures. The first is a vicious cycle. Gaps in formal veterinary care lead to more unregulated providers. Their limited training and reliance on black-market drugs drive the misuse of antibiotics. This breeds superbugs that undermine both animal and human health, creating even more sickness and straining our fragile health systems.

The second path creates a virtuous cycle. We give the para-vet a badge (legal recognition). We give him a proper spellbook (standardized training). We invite him to join the league of heroes (systemic integration). In this future, a newly professionalized provider improves animal health through prevention and smart treatment. This reduces the overall need for antibiotics. He becomes a trusted guardian of his community’s health and a vital sentinel protecting the rest of the world from the next disease outbreak.

This is not a fringe issue. This is a cornerstone of global health security. As the nations of the world declare war on AMR, the professionalization of the para-vet must be written into every country’s battle plan (Thomas, 2025). They are our ground troops, the ones who can turn policy into practice on the farm. Investing in them is a direct investment in the One Health ideal: the simple, powerful idea that the health of people, animals, and the environment are all woven together.

The time for pilot projects and academic debates is over. The path forward requires bold, concerted action.

A Call to Action for Governments and Veterinary Leaders:

1. Rewrite the Rulebook: Update your national veterinary laws. Create a formal, legal home for the para-veterinary professional. Use the world's best practices from WOAH and others to define what they can and cannot do, creating a clear, tiered system of care.

2. Adopt the Gold Standard: Make the WOAH CAHW Competency Guidelines the official national standard for training and accreditation. End the chaos of inconsistent, ad-hoc training. Ensure every provider learns from the same high-quality spellbook.

3. Build One Team: Use strategic tools like the WOAH PVS Pathway to formally integrate these professionals into your national system. Give them a role in disease surveillance, a seat at the table, and a connection to the national data network. Turn your scattered freelancers into a cohesive public health army.

A Call to Action for Donors and Aid Organizations:

1. Build Systems, Not Projects: Stop funding short-term training workshops that evaporate when you leave. Invest in the long-term enabling environment. Fund the advocacy needed to change laws. Help build legitimate, quality-controlled supply chains for veterinary medicines. Teach business skills, not just technical skills.

2. Demand Quality: Make your funding conditional on quality. Insist that any training program you support aligns with the international WOAH guidelines. Use your financial leverage to raise the bar for everyone.

3. Invest in Success: Focus on creating sustainable careers. Help providers form cooperatives, access micro-finance, and build viable businesses that don't rely on your subsidies to survive.

In the end, the story comes back to the farmer, his sick cow, and the man on the motorbike. The choice we face is what happens next. Do we leave them to fumble in the dark, using failing keys on ever-changing locks? Or do we give that man a new set of keys, a map, and a radio to call for backup when he needs extra help? Do we turn a well-meaning gambler into a trained first responder? By investing in the transformation of these millions of “animal friends,” we do more than just save livestock. We strengthen food security, build economic resilience, and forge a vital frontline defense in the global war against superbugs. This is not a cost. It is one of the smartest investments we can make in our shared, one-health future.

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World Organisation for Animal Health. (2025a, July). PVS Pathway. WOAH - World Organisation for Animal Health. https://www.woah.org/en/what-we-offer/improving-veterinary-services/pvs-pathway/

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It was only in trying to uncover the details of this "Beatocello" concert, an event we had never heard of prior to our trip, that we began to learn about the astonishing life of Dr. Beat Richner, the man behind the music and the medicine. The more we learned about the story of this incredible physician and his life's work, the more fascinated we became, until, in one fell swoop, our fascination turned to poignant regret. We learned that Dr. Richner had passed away just a couple of months before our arrival in Cambodia. We had missed the chance to witness a legend, but his story has stayed with us ever since.

Dr. Beat “Beatocello” Richner: A Physician's Journey

Dr. Richner's story, eloquently captured in his New York Times obituary, is one of unwavering dedication. After training in pediatrics at the Zurich Children’s Hospital and graduating in 1973, his path took a dramatic turn. In 1974, the Swiss Red Cross dispatched him to Cambodia, a nation already mired in a brutal civil war between the government of Lon Nol and the encroaching rebel forces of the Khmer Rouge. Dr. Richner's mission at the Kantha Bopha children's hospital came to an abrupt halt when the Khmer Rouge seized power in 1975, expelling foreign aid workers and plunging the country into darkness.

Forced to return to Zurich, Dr. Richner resumed his career, opening a private practice in 1980 and pursuing the conventional track of a successful doctor in the developed world. Meanwhile, Cambodia was enduring the genocidal horrors of the Khmer Rouge regime under Pol Pot. Between 1975 and 1979, an estimated two million people, over a quarter of the country's population, were killed, including the vast majority of its teachers, doctors, nurses, scientists and intellectuals. The healthcare system was completely obliterated. To be an intellectual, to wear spectacles, to live in the city or to have a graduate education made them targets.

Though physically back in Switzerland, Dr. Richner’s heart remained in Cambodia. In 1991, following a peace agreement and the arrival of the UN Transitional Authority (UNTAC), the Cambodian government sent a formal request: would he return to rebuild and manage the Kantha Bopha Children's Hospital, the very institution the Khmer Rouge had destroyed?

Dr. Richner did not just accept; he returned with a vision far grander than restoring a single building. In March 1992, he established the Kantha Bopha Foundation in Zurich to secure funding and relocated to Phnom Penh with the express goal of rebuilding the nation’s pediatric healthcare services from the ground up. By November 2nd, 1992, against all odds, the first Kantha Bopha hospital was up and running, with streams of desperate parents and sick children knocking down its doors.

An Empire of Healing

The need was staggering. The Kantha Bopha I hospital was soon overwhelmed, handling over 1,000 outpatient consultations and admitting 350 inpatients daily. This led to a remarkable period of expansion fueled by Dr. Richner's relentless fundraising:

• October 1996: Kantha Bopha II opened in Phnom Penh, built on land donated by King, and Prime Minister Norodom Sihanouk himself.

• March 1999: Jayavarman VII Hospital (often called Kantha Bopha III) was inaugurated in Siem Reap, bringing world-class care to the doorstep of the historic Angkor temples.

• 2001: A maternity ward was added to the Siem Reap hospital, specifically to care for mothers living with HIV/AIDS and prevent mother-to-child transmission.

• 2005 & 2007: Kantha Bopha IV and V, two new state-of-the-art hospitals, were constructed in Phnom Penh to support the overburdened Kantha Bopha I.

By 2017, this network of hospitals provided over 80% of all pediatric healthcare in Cambodia, treating every child for free. The statistics from his foundation's website (wayback machine archive link, as the original website has been modified and I can no longer find this page) are a testament to the scale of his achievement:

Over the last 23 years the Kantha Bopha hospitals have treated 13 million outpatients & 1.56 million seriously ill children requiring hospitalisation.

The Beatocello Solution: Music, Medicine, and a Message

In addition to his remarkable feat of institution-building, Dr. Richner devised an ingenious way to connect the vast, swirling crowds of tourists in Cambodia to his philanthropic work. During his medical training in the 1970s, he had cultivated an artistic alter ego he dubbed "Beatocello", a musical comedian who charmed audiences with his cello and witty banter. He had performed across Europe, but in Cambodia, this persona became his most powerful fundraising tool.

He established a weekly, free concert in Siem Reap. I can only imagine the scene: a hall filled with tourists, fresh from the awe-inspiring ruins of Angkor Wat, settling in for a cello performance. But it was so much more than that. Dr. Richner, a true polyglot, would address the packed house in English, German, and French. He was a master showman, interspersing beautiful, soulful renditions of Bach, with stories, humor, and a direct, impassioned plea. As one attendee noted, he would often ask the younger tourists to donate blood, the older ones to donate money, and those in between to donate both. He would screen films showing the daily reality of his hospitals, offering unvarnished transparency to potential donors.

He would gently rib people in the crowd, disarming them with his wit before delivering the hard-hitting truths about the state of healthcare and the horrors the Cambodian people had endured. Through his music and his words, he told the story of a nation's wounds and how his hospitals were trying to apply a healing salve.

The Fire of a Principled Physician

Those who attended his concerts didn't just hear music; they witnessed the fire of Dr. Richner's convictions. As another travel blogger who saw him perform recalled (another wayback machine link, since the direct link does not work anymore), he didn't pull any punches. He was deeply critical of the policies of international organizations like the World Health Organization (WHO) and UNICEF, which he accused of promoting a dangerous philosophy: that poor countries must accept a lower standard of medical care that matches their economic situation. This philosophy, the basic underlying principle of global health, was also championed by Paul Farmer and his Partners in Health movement.

You learn about Cambodia’s past and present

Having lived in Cambodia for the past 23 years, Dr. Richner has quite the knowledge about Cambodia’s past and present. You won’t just get Cello show but also a knowledgeable insight into Cambodia’s current political and social complexities, especially in the health division. Although remaining ‘politically correct’, Dr. Richner touches on some important aspects of Cambodia’s (and the world’s) health policies that leave us very much apprehensive and perplexed.

You get a humorous performance

Having been quite the musical comedian in his time, Dr. Richner will be sure to put on a show full of witty remarks and comedic behavior. Speaking a variety of languages including Swiss, German, French and English, and with considerable knowledge of world politics, be prepared to get picked out of the crowd for some innocuous humor.

You hear the sweet sounds of the Cello

Dr. Richner goes by the stage name of Beatocello, which comes from the combination of his first name and his favourite instrument, the Italian Cello. Having played the Cello for most of his adult life he is quite the performer and will put on a beautiful show of bittersweet, soulful music to your ears and to your heart, telling the story of the people of Cambodia through each of his performances.

Dr. Richner vehemently rejected the idea that the quality of healthcare should be any different in Cambodia than in Switzerland. He would swipe his cello bow dismissively and argue that while this might be the reality, it was not a reality we should ever accept. To him, this approach amounted to a policy of “poor medicine for poor people in poor countries.” He believed that tolerating this was to be complicit in what he bluntly called a “passive genocide of children.” His words were strong, born from a profound belief that a child’s right to quality healthcare is a universal human right, not an economic privilege.

Another blogger, who seemed to have attended his Beatocello sessions, and seems to be located in Cambodia, writes about the fire of Dr. Richner:

Dr Beat Richner is quite a performer — the founder, director and chief fundraiser of the Kantha Bopha group of children’s hospitals in Cambodia, he is passionate, eloquent — and a rather good cellist.

Every Saturday night Dr Richner attracts a large audience for his free ‘Beatocello’ concert at the Kantha Bopha 3 hospital in Siem Riep. The crowd, almost entirely tourists dropping in on the way to the nearby Angkor Wat, are treated to some lovely Bach, interspersed with an impassioned lecture in defense of his controversial approach to children’s healthcare in Cambodia.

He doesn’t pull any punches: the international community, through the World Health Organization, is accused of accepting and even promoting a situation where countries have to match the quality of their healthcare to their wider economic situation.

But that seems fair enough doesn’t it? As I heard him speak, I couldn’t help thinking that it’s only reasonable that we live within our means — if you’re a poor country you can only afford to provide a certain level of care. It’s not nice, but it’s the way things work — isn’t it?

No, absolutely not said Dr Richner, anticipating the objection and swiping his cello bow dismissively. This may be how things are, but it is not how they have to be. In fact, accepting this situation, in his view, amounts to a policy of “poor medicine for poor people in poor countries”. If we tolerate this, we are complicit in nothing short of a “passive genocide of children”. Strong words.

The Man Behind the Myth

For all the grandeur of his achievements, Dr. Richner lived a life of extreme austerity. The New York Times painted a quaint picture of the good doctor, a man whose life was wholly dedicated to two things: the hospital and his cello.

“His life was very limited and connected to only two things,” said Dr. Ky Santy, who became the director of Kantha Bopha after Dr. Richner stepped down for health reasons last year. “First, to the daily life of the hospital; and second, to the cello.”

Living austerely, Dr. Richner worked 12 hours a day, took no vacations and drove a 22-year-old car. He used a corner table at the hospital canteen as his office, meeting with staff there as he ate his customary breakfast of two hard-boiled eggs and a cup of coffee. For lunch, he would eat the same fare in the same spot before embarking on his hospital rounds. At 3:30 p.m. he would practice music.

We were humbled and deeply moved by these details. Standing in Siem Reap in the last week of 2018, we felt the weight of our missed connection. Dr. Richner had passed away on September 9th of that year, just weeks before our visit.

The endeavor of one man, armed with a cello and an unbreakable will, to provide sophisticated, compassionate healthcare in a country ravaged by war, genocide, and corruption remains a towering beacon of hope. The fact that he not only provided care but also fought to change the global conversation around it, taking his fight directly to the Cambodian government and the world's most powerful health organizations, is nothing short of heroic. He built a unique healthcare ecosystem that was Cambodian-led, ensuring that the hospitals would live on long beyond him, now under the capable leadership of his successor, Dr. Ky Santy. Dr. Richner's cello may be silent now, but his legacy of healing and justice plays on in the millions of lives he saved.

I have been working on my PhD dissertation, which deals with antibiotic overuse at the community level in rural India, specifically in underserved and impoverished communities. I have been thinking a lot of about how we, as policymakers, tend to oversimplify the issues at work. And I should know. Because I was a part of the team that drafted the background document informing the National Action Plan on Antimicrobial Resistance (NAP-AMR) in India!

It goes without saying, that at this point, few public health concerns are as complex and stubborn as the irrational use of antimicrobials at the community level. People worldwide routinely take antibiotics for viral infections, store leftover pills for future ailments, or pressure pharmacists, who are only too compliant keeping an eye on their bottomlines, into dispensing medications without a prescription. Each action, though seemingly insignificant on its own, magnifies the global threat of antimicrobial resistance. In 2019, the World Health Organization (WHO) designated antimicrobial resistance (AMR) as one of the top ten threats to global health, warning that drug-resistant infections could lead to 10 million deaths annually by 2050 if left unchecked.

Yet, it is not enough to just point fingers at public misuse or to simply mandate policy changes. Irrational antibiotic consumption is more than a matter of public ignorance; it is a tangled web of cultural habits, inadequate diagnostic tools, and political fragmentation. More formally, it exemplifies what Horst Rittel and Melvin Webber described in 1973 as a “wicked problem,” a concept further refined by multiple scholars, including Guru Madhavan in his exploration of systems engineering. Incidentally, I picked up Madhavan’s incredible book “Wicked Problems: How to Engineer a Better World” when I was flying out from Kolkata, heading back to Baltimore. Here’s two tips: first, it is an incredible read, what the Telegraph would characterize as unputdownable; second, do not read it while in a flight, mainly because of the number of examples he draws from aviation incidents. So, of course, I wanted to know more about Madhavan’s work, and ended up reading through his National Academies blog post, and this awesome discussion on the Oxford Martin School YouTube channel. Anyway, back to this problem, then.

Wicked problems resist clean solutions, are characterized by the “shifting goal posts” issue, and often become more intricate when we attempt to fix them. In this post, I will try to explore how irrational antibiotic use represents the intersection of three problem layers — soft, hard, and messy — that collectively produce a singular, deeply rooted quagmire. I will also argue that the one-dimensional fixes we have tried have, bya and large, failed to address the complexity of unrestrained antimicrobial usage at the community level.

Soft Problems: The Human Dimensions

Much of the chaos stems from human beliefs, attitudes, and behaviors. These soft problems manifest in the social norms, cultural values, and informal knowledge networks that shape antibiotic-seeking behavior. In many communities, antibiotics are seen as fast-acting “magic bullets”. If someone has a fever, cough, or any lingering malaise, the default assumption is often that antibiotics (and a steroid boost) offer the quickest route to recovery. A grandparent might insist on giving their grandchild powerful pills for symptoms that are likely viral, not because they are ill-intentioned, but because they rely on lived experience and folk wisdom passed down for years.

Deep-rooted beliefs about health, often influenced by family or social groups, can override more formal sources of knowledge. A person may know on some level that antibiotics do not alleviate viral infections, yet still reach for them in moments of desperation or uncertainty. A 2024 analysis of awareness campaigns conducted in Europe provides some discouraging insights. Most of the campaigns did not result in any practice changes (despite upticks in knowledge levels), and only two campaigns looked at long term follow-up data. They found that while there was a large reduction in antibiotic prescriptions in the immediate aftermath of the program launch, over time, this effect waned and antibiotic usage slowly trickled up. If this is the state of affairs in affluent western European countries, where access to healthcare is assured, and social welfare schemes are relatively generous, imagine what can happen in a more impoverished setting with none of these safety nets.

It has been our experience that knowledge campaigns alone fail to curb inappropriate antibiotic use in communities where trust in formal healthcare channels is limited, or where resources for diagnostics and follow-up care are scarce. Habits and cultural norms can be every bit as stubborn as biological pathogens. They are imbued with history, shaped by societal pressures, and resistant to the straightforward logic of medical science.

Another potent driver is fear. Where there is a history of limited healthcare access, people sometimes cling to antibiotics as an all-purpose safeguard against serious illness. That protective instinct is compounded by social hierarchies in which local leaders, elders, or more knowledgeable neighbors, rather than trained clinicians, who are often regarded with some level of suspicion, become key gatekeepers of health information. Any measure that seeks to address antibiotic misuse must engage with these community influences. If interventions overlook cultural nuances, they run the risk of being dismissed or, at best, partially adopted.

Hard Problems: The Scientific and Technological Realities

Irrational antibiotic use is also entangled with scientific and logistical constraints. Antibiotics are remarkable pharmacological tools, but they are only as good as our ability to use them correctly. Bacterial populations evolve through genetic mutations and horizontal gene transfer, making them adept at dodging once-potent drugs. When antibiotics are overused or misused, the evolutionary pressure selects for hardy bacteria that can withstand standard treatments. The result is a world where lifesaving medications gradually lose effectiveness, turning once-minor infections into formidable foes.

To add to our woes, the pipeline for developing new antibiotics has weakened, largely because pharmaceutical companies find antibiotic research less profitable than chronic disease medications. This issue is complex enough to deserve its own post, but in a nutshell, the cost of R&D is high, and new antibiotics are prudently saved as last-resort treatments, limiting the potential for financial returns. Meanwhile, healthcare systems in many parts of the world struggle with inadequate diagnostic capabilities. When a patient arrives at a community clinic with a fever, there may be no rapid test to determine whether the infection is viral or bacterial. Clinicians, under pressure to deliver quick relief, sometimes resort to prescribing antibiotics “just in case.”

These gaps in diagnostics and drug development highlight the technical and infrastructural barriers that shape our daily use of antibiotics. Any policy aimed at curbing misuse must grapple with these structural weaknesses. Even if a region has robust public health guidelines, lack of access to rapid diagnostics can make following those guidelines difficult. Scientific advancements like the creation of low-cost, point-of-care tests could potentially transform the way we manage infections; sadly, progress remains slow, especially in low-resource settings. This leaves us in a precarious situation: we possess potent tools to treat bacterial infections, but we lack both the incentives and the infrastructure to ensure they are employed wisely.

Messy Problems: Policy, Governance, and Social-Ecological Quagmires

The misuse of antimicrobials also sits at the center of a messy policy and governance landscape. Governments vary widely in how they regulate antibiotic distribution, and inconsistent laws lead to further complications. Even where strict regulations exist, enforcement can be weak. Pharmacies may overlook the rules to maintain income, while officials might turn a blind eye out of fear of political backlash. Some communities function almost entirely in an informal economy, where the idea of a formal prescription process is largely alien.

In certain contexts, antibiotics are a livelihood. Sellers who supply them without medical oversight are not merely exploiting the situation; they might be meeting local demand in places where healthcare facilities are scarce. Smuggled or counterfeit antibiotics also enter the picture, distributed through unregulated channels that no public health agency tracks. Domestic or international borders, now a matter of great local and global political concern, become fluid when it comes to microbial threats, as resistant bacteria can move freely with travelers or through shared water sources, rendering local regulations irrelevant if neighboring regions remain lax.

These messy realities underscore the role of economics and governance in shaping antibiotic use. Even the most carefully devised policy can fail if it is not accompanied by mechanisms to ensure compliance and universal access to healthcare alternatives. A well-meaning push to clamp down on over-the-counter antibiotic sales might lead to the emergence of an underground market, potentially increasing the circulation of unsafe or substandard drugs, and driving the whole system underground, taking it out of the policy and public view. Solutions that ignore this interplay between economics, politics, and local cultural dynamics may end up exacerbating the very problem they aim to resolve.

The Wicked Collision: Irrational Antimicrobial Use as a Perfect Storm

When soft, hard, and messy problems converge, we find ourselves grappling with a perfect storm of complexity. Irrational antibiotic use stands out as a textbook example of this convergence. It is wicked because its parameters are always shifting, its definitions vary among stakeholders, and its interconnected factors often generate unintended consequences (I will write about this in more details in a future post).

Complexity begins with the question of what “irrational antibiotic use” even means. Some interpret it as taking antibiotics without a valid prescription, while others focus on incomplete doses or incorrect drug choices or incoherent fixed-dose combinations. Healthcare providers might frame irrational use in terms of knowledge deficits among the public, whereas community members might identify healthcare barriers, like cost or lack of trust in medical institutions, as a bigger headache. Disparate definitions spawn disagreements over how to tackle the problem, making it difficult to standardize any response.

Interdependencies also multiply. Community-level behaviors shaped by social pressures will not change unless governance structures rein in unregulated sales, yet those same governance structures may be powerless without robust scientific tools to diagnose infections accurately. Every attempt to solve one element risks aggravating another. When regulations become too stringent, people may shift to clandestine markets. When new diagnostic tests remain expensive, clinics that serve underprivileged populations can’t adopt them, leaving prescribers to guess. This interplay deepens the tangle.

Irrational antibiotic use also fits the wicked profile because there is no clear “end point.” Even if inappropriate usage rates plummet for a time, new resistant strains emerge, and the challenge reappears in a fresh form. Nowhere is this exasperation better exemplified than in the persisting problem of tuberculosis and malaria. We have developed a number of effective and efficacious regimens against both diseases (HRZE for TB; chloroquine and analogs for malaria), which, over time, have lost their edge. Then we have come up with combination therapies to counteract these turbocharged resistant pathogens — for TB these included newer drugs like bedaquinine, pretomanid or delamanid; and for malaria, they included a range of Artemisinin based combination therapies. But our woes are far from over, as the microbial marauders are figuring out a way to resist these newer agents as well. So, where does this end? Which goal post are we targeting?

The complex evolutionary dynamics of bacteria ensure that antibiotic stewardship must be an ongoing, adaptive process rather than a finite effort. In the words of Rittel and Webber, wicked problems have no simple stopping rule, and each “solution” often begets a new wave of complications. While Paul Farmer said this in a very different context, I can contend that this is also like “fighting the long defeat”. In the end, as Pasteur foretold, the microbes will have the last word.

Why Simple Fixes Rarely Work

Education campaigns alone frequently fall short because knowledge does not always translate into practice. In fact, having seen what I have in the past decade, I would say that the knowledge-practice gap is more of an unbridgeable gulf in reality than researchers or policymakers will admit. People might read that antibiotics are ineffective for viral infections, but they are still going to seek them out when faced with uncertain symptoms or a lingering cough. Fear, social expectation, and personal anecdotes of “a one pill cure” can outweigh public health messaging.

Technological breakthroughs can quickly hit roadblocks if they fail to address affordability or come without the necessary policy and financial support. A cutting-edge diagnostic device cannot help communities that cannot afford it, and a new antibiotic does little good if profit-driven systems delay its development or limit its distribution. These scientific or infrastructural advances remain sidelined when market forces and policy frameworks are not aligned to ensure widespread implementation. However, while this is true, I do not, for one moment, believe that costs can be a way for gatekeeping access to a truly disruptive innovation. HIV drugs, for instance, started out being super expensive — to the point where even patients in the US were not able to afford it on a regular basis. In less than a decade after their market launch, we managed to bring down costs. And today, they barely cost anything. I don’t know what the pharma executives feel about this, but it has given us a way to approach costs and balance them with economies of scale. And considering the scale of the AMR problem, any effective intervention can be easily scaled.

But, till we have the silver bullet to target AMR, our best bet remains to target irrational AMU. Top-down policy changes can seem promising but may stumble if they ignore local realities. Restrictions on antibiotic sales might be promulgated by health ministries, but communities without the resources to see a trained clinician may find these regulations burdensome, or even contributory to higher levels of morbidity and mortality. In such environments, what starts as a sincere effort to protect the public can end up driving antibiotic use underground or encouraging the proliferation of counterfeit medications. Each of these one-dimensional solutions fails precisely because it underestimates the tangled web of soft, hard, and messy factors.

Case-in-Point: The Community Pharmacy Conundrum

A community pharmacy in a low- or middle-income neighborhood neatly encapsulates these colliding realities. Pharmacies are more accessible than hospitals, yet they often lack the resources and diagnostic tools found in larger health centers. Customers arrive seeking immediate relief, armed with cultural beliefs that antibiotics are a one-size-fits-all solution. Pharmacists themselves might be poorly paid, creating an incentive to sell whatever the clientele demands. Public health policies that restrict over-the-counter antibiotic sales can feel like a threat to the pharmacy’s livelihood, leading them to skirt regulations. It never gets old, when I tell medical students or healthcare professionals in the US that in India I can get a hold of ANY antibiotic at any time from almost any pharmacy. Even costlier ones, higher on WHO’s AWaRe list of antimicrobials.

So, it stands to reason, that even the most stringent of policies can dissolve into irrelevance if the community’s trust in official healthcare institutions is low. People in desperate need of relief may not only ignore rules but also view them as barriers to necessary treatments. That encourages an illicit market, where the drugs may be of dubious quality, potentially accelerating the spread of resistant bacteria. Attempting to solve one part of the problem, whether through stricter policy, better training, or public education, can backfire if the other dimensions remain unaddressed.

The One Health Perspective: Beyond the Human

Wicked problems also transcend human medicine, particularly when discussing antibiotic use. One Health, an integrated approach that recognizes the interconnectivity of human, animal, and environmental health, highlights how antibiotic misuse in livestock can dwarf consumption in clinical settings. Livestock are often fed antibiotics at low doses to promote growth and prevent disease in crowded conditions. While that practice might enhance productivity, it also introduces antimicrobial residues in food and, over time, spawns resistant bacterial strains that can jump to humans through direct contact or via the food chain. This is a big enough problem to deserve its own book, let alone a blog post!

Environmental factors further complicate the landscape. Wastewater from drug manufacturing plants can contain antimicrobial residues that seep into local ecosystems. Rivers and soil contaminated by these residues become prime grounds for resistant microbes to thrive and spread. Even if human antibiotic consumption at the community level becomes more regulated, these environmental and agricultural reservoirs could still ignite new waves of resistance. No solution can be complete without addressing each of these interconnected domains.

Toward Multifaceted Solutions: An Adaptive Strategy

Given the wicked nature of the challenge, only a multifaceted, adaptive approach can hope to contain irrational antibiotic use. Rather than pinning hopes on a single remedy, successful strategies must integrate insights from anthropology, sociology, clinical medicine, veterinary science, and policy studies. Collaboration across these fields recognizes that human behavior is interlinked with scientific realities and shaped by governance structures.

Community engagement is one vital step. Instead of deploying top-down directives, public health officials must partner with local leaders, pharmacists, and clinicians to create interventions that resonate with local beliefs and practices. Understanding why communities value antibiotics so highly, and building trust in alternative solutions, can make a difference. Attempts to incorporate cultural practices into official healthcare channels are more likely to succeed than imposing external rules that feel disconnected from daily realities.

Strengthening health systems also remains crucial. Investment in diagnostic technologies that are affordable and user-friendly can empower clinicians to discern bacterial from viral infections, reducing guesswork and unnecessary antibiotic prescriptions. Training healthcare workers, both in the formal and informal sectors, on antibiotic usage and stewardship can help them resist social or commercial pressures to prescribe medication needlessly. Economic incentives for pharmaceutical companies to research and develop new antibiotics or better diagnostic tools are essential, but they must be paired with thoughtful policies that ensure equitable distribution and responsible use.

All such measures need to be iterative. A policy that proves effective in one setting may fail in another, due to cultural or economic differences. Periodic assessments of what is working and what is not, along with the flexibility to pivot in response to new data, are the hallmarks of an adaptive strategy. That approach aligns with the spirit of Rittel and Webber’s original description of wicked problems, which noted that solutions are rarely final and typically need constant refining.

Embracing Complexity for Real Impact

If you have managed to stick it out this far, congratulations, you, like me, are a fellow AMR nerd. And that is how I know this section will feel like a cop out to you. Because, it does to me.

Irrational antibiotic use at the community level illustrates the messy convergence of soft, hard, and messy problems, where human behavior, scientific reality, and policy intricacies fuse into a wicked challenge. The casual act of taking “just one more pill” when dealing with a routine cold is anything but harmless when replicated globally. To confront a wicked problem, we must abandon the idea that knowledge alone will transform behaviors, that new medical technologies will inherently solve structural injustices, or that policy mandates will work in isolation. Each dimension is crucial, but each depends on and interacts with the others. Cultural beliefs must be addressed with sensitivity, infrastructural gaps must be bridged with innovation and investment, and political and economic barriers must be tackled through nuanced, enforceable regulations.

Embracing the complexity of this wicked problem demands humility. There is no singular cure or miracle plan that will magically eliminate irrational antibiotic use. Instead, we can aim to navigate the storm more skillfully by weaving together collaborative, interdisciplinary strategies that respond to evolving patterns of resistance, community needs, and policy opportunities. That approach acknowledges the interconnected nature of our health systems, environments, and societies, reinforcing the fundamental reality that antibiotic stewardship is a shared responsibility.

So, the next time someone casually recommends you take a powerful antibiotic for a mundane sniffle, remember that the story behind that simple suggestion is steeped in cultural lore, scientific challenges, and policy gaps. If we truly wish to preserve the efficacy of these life-saving drugs, we need to confront the wickedness of the problem head-on, we need to understand it not as a puzzle to be solved once and for all, but as a continuous, dynamic process requiring vigilance, adaptability, and collaboration.

In this intriguing essay, Bhaumik argues that epistemic injustice is deeply prevalent in NTD research, highlighting the historical context of tropical medicine as a tool to maintain colonial power structures. He emphasizes that despite the end of colonial rule, the NTD research ecosystem maintains a “feudal structure” that continues to marginalize experts from LMICs where these diseases are most prevalent. If you are inclined to learn more about his reasonings behind calling the current global health research ecosystem as a feudal one, please check out his essay in BMJ Global Health.

The PLOS NTD paper provides several examples of this feudal structure in action:

• Funding bias: Unsurprisingly, a disproportionately large amount of NTD research funding goes to institutions in non-endemic countries, perpetuating a power imbalance.

• Helicopter research: Researchers from high-income countries often conduct research in LMICs without meaningfully involving local experts. LMIC or local experts are often relegated to the roles of data collectors, without much intellectual or experiential involvement in the processes.

• Devaluation of local knowledge: Knowledge generated in LMICs and published in local journals is often seen as less credible.

• Limited leadership opportunities: The lack of opportunities for LMIC experts to lead NTD projects impacts their careers and reinforces their perceived lack of credibility in the global research space.

• Narrow definition of NTDs: The current definition, which emphasizes neglect and the link between disease and poverty, may incentivize actors to maintain a certain level of neglect and prioritize diseases amenable to “magic bullet” solutions, potentially sidelining crucial areas of research. I loved this particular point, because this syncs well with my pet peeve that the discussion around AMR is too often around antimicrobial agents, and not often enough around human behavior.

As I was reading this piece, I realized that Paulo Freire’s “Pedagogy of the Oppressed” provides a valuable lens for analyzing Bhaumik’s arguments, exploring the interplay between power, knowledge, and liberation. Freire argues that true liberation requires a “problem-posing” approach to education that empowers the oppressed to become critical thinkers and agents of their own transformation. In my opinion, this perspective directly connects with Bhaumik’s call for decolonizing the NTD research ecosystem.

The Banking Model of Research

Bhaumik’s critique of the current NTD research ecosystem echoes Freire’s condemnation of the “banking” model of education, where knowledge is deposited into passive recipients (Ah! Medical School!). Just as Freire argues that students should be active participants in the learning process, Bhaumik advocates for researchers in endemic countries to be recognized as knowledge creators and leaders in NTD research. The current system, characterized by helicopter research and the devaluation of local knowledge, perpetuates the “culture of silence” Freire describes, where the voices of the oppressed are silenced.

Dialogue and Collaboration

Freire’s emphasis on dialogue as a tool for liberation resonates with Bhaumik’s call for co-design and co-production of research. Freire believes that genuine dialogue, marked by respect and mutual learning, is essential for transforming oppressive structures. Similarly, Bhaumik suggests that equitable collaboration, where researchers from both endemic and non-endemic countries work together as equals, is crucial for producing more relevant and impactful NTD research.

Conscientização and Action

Both Freire and Bhaumik emphasize the importance of critical consciousness (conscientização) in challenging oppressive systems. Freire argues that the oppressed must recognize the reality of their oppression and actively participate in their liberation. Bhaumik, through the lens of epistemic justice, highlights the need for researchers in endemic countries to be empowered to challenge the existing power structures within the NTD research ecosystem. The paper’s call for diversifying leadership, restructuring capital flows, and enhancing transparency in research processes aligns with Freire’s concept of praxis—the integration of reflection and action to transform the world.

Beyond Methodological Solutions

While Bhaumik offers suggestions for addressing epistemic injustice, like diversifying leadership and adopting deliberative epistemic repair, Freire’s work cautions against relying solely on methodological solutions. In a personal message to Bhaumik, I complained that his piece remains too theoretical, and I think Freire could have helped him overcome this! In “The Pedagogy of the Oppressed”, Freire argues that true transformation requires a fundamental shift in consciousness and a commitment to challenging the underlying power dynamics. Applying this perspective to Bhaumik’s paper, decolonizing the NTD research ecosystem necessitates not just changes in practices but a genuine commitment to recognizing and valuing the knowledge and expertise of those in endemic countries.

Epistemic Injustice as a Form of Oppression

Bhaumik’s central argument—that epistemic injustice is woven into the fabric of NTD research—can be seen as a specific manifestation of the broader concept of oppression that Freire dissects. Freire analyzes the various mechanisms through which the oppressor maintains control, including the suppression and distortion of the oppressed’s knowledge and experiences. Similarly, Bhaumik argues that the historical power imbalance between high-income countries and LMICs continues to shape the NTD research landscape, leading to the devaluation and silencing of knowledge and expertise from endemic regions. He brings up Miranda Fricker’s theory on epistemic injustice, and brings them to life with wonderfully visual examples, which helps the reader understand the overly verbose descriptions of Fricker.

Decolonization as a Liberatory Praxis

Freire’s call for a pedagogy of the oppressed that dismantles the banking model of education and empowers the oppressed to become agents of their own liberation directly parallels Bhaumik’s advocacy for decolonizing the NTD research ecosystem. Both authors emphasize the need to challenge and transform the existing structures that perpetuate inequality and injustice. Bhaumik’s recommendations for restructuring funding flows, promoting diverse leadership, and fostering genuine collaborations echo Freire’s notion of praxis—the cyclical process of reflection and action necessary for achieving liberation.

Bhaumik emphasizes that simply including researchers from LMICs is insufficient if the underlying power structures remain unchallenged; genuine change requires a fundamental shift in how knowledge is produced and valued. This aligns with Freire’s argument that true liberation necessitates a transformation of consciousness and cannot be achieved through superficial adjustments or handouts from the oppressor.

Both authors advocate for a move away from the “banking” model, where knowledge is seen as a commodity to be deposited by those in power, towards a dialogical approach that recognizes the oppressed as co-creators of knowledge. Bhaumik’s examples, such as helicopter research and the focus on diseases amenable to “magic bullet” solutions, exemplify how the current system prioritizes control and efficiency over genuine collaboration and understanding of local needs.

Freire argues that dialogue, characterized by humility, love, and mutual trust, is fundamental for the oppressed to critically examine their reality and develop a plan for transforming it. Bhaumik’s call for co-design and co-production of research, transparency in research processes, and genuine partnerships between researchers in endemic and non-endemic countries reflects this need for dialogue and co-creation.

Challenging the “Culture of Silence”

Freire’s concept of the “culture of silence,” where the voices of the oppressed are silenced and their knowledge and experiences are deemed irrelevant, provides a framework for understanding the epistemic injustice prevalent in NTD research. Bhaumik highlights how the existing research ecosystem marginalizes experts from endemic countries, devalues their perspectives, and limits their opportunities for leadership and recognition. This silencing not only perpetuates inequalities but also hinders the development of more effective and relevant solutions to NTDs, as it disregards the valuable insights of those most affected by these diseases.

Transformative Potential of Research

Both Freire and Bhaumik see knowledge production as a powerful tool for social transformation. Freire believes that a problem-posing approach to education can empower the oppressed to challenge and change their reality. Bhaumik, in advocating for a more just and equitable NTD research ecosystem, suggests that research can be a force for positive change, not only by generating effective solutions to diseases but also by fostering empowerment and agency among those in endemic regions.

Bringing in Miranda Fricker’s model of epistemic injustice Bhaumik further enriches this discussion. Fricker’s work, which focuses on the ethical and social dimensions of knowledge production, helps to unpack the specific ways in which individuals and groups are marginalized and silenced in their capacity as knowers. She distinguishes two primary forms of epistemic injustice:

Testimonial Injustice

This occurs when a speaker receives less credibility than they deserve due to prejudices held by the hearer. In the context of NTD research, this manifests in the devaluation of knowledge generated by researchers in endemic countries and published in local journals. The entrenched power imbalances lead to a systematic discounting of perspectives and expertise from the Global South, hindering both scientific progress and the development of effective solutions for the communities most affected by NTDs.

Hermeneutical Injustice

This arises when prejudices embedded in the shared interpretive resources of a community prevent individuals from making sense of their social experiences. Bhaumik’s paper illustrates this through the narrow definition of NTDs and the prioritization of diseases amenable to “magic bullet” solutions. This framing, often driven by funding priorities and the agendas of institutions in high-income countries, can obscure the complexities of NTDs and neglect crucial areas of research that may not fit neatly into existing paradigms.

Addressing Epistemic Injustice: A Call for Dialogical Transformation

Both Freire and Fricker, in their respective ways, point towards dialogue as a crucial element in dismantling oppressive structures and fostering epistemic justice. Freire emphasizes the transformative potential of genuine dialogue, marked by humility, love, and mutual trust, as a means for the oppressed to gain critical consciousness and challenge the dominant narratives. Fricker advocates for “deliberative epistemic repair,” which involves actively recognizing and countering the prejudices that lead to testimonial and hermeneutical injustice. This includes giving greater weight to the testimonies of marginalized knowers and challenging the dominant interpretive frameworks that obscure their experiences.

Bhaumik’s recommendations for decolonizing the NTD research ecosystem resonate with these ideas. Diversifying leadership, restructuring capital flows, and enhancing transparency in research processes create the structural conditions necessary for more equitable participation. Co-design and co-production of research, along with the adoption of anti-oppressive teaching practices, cultivate the dialogical space for genuine collaboration and mutual learning.

The insights from Freire, Fricker, and Bhaumik converge on a powerful message: decolonizing the NTD research ecosystem is an ethical imperative, a scientific necessity, and a critical step towards achieving health equity and global justice. We can see how decolonizing the NTD research ecosystem is not merely about adopting new methods or including more researchers from LMICs. It requires a deeper commitment to dismantling the power structures that perpetuate inequality and to creating a research environment where the knowledge and expertise of all participants are valued and respected. True decolonization, like true liberation, necessitates a fundamental shift in consciousness and a commitment to genuine collaboration and co-creation of knowledge.