New Delhi: There are different suggestions doing the round. The union health minister Ghulam Nabi Azad is pushing for a new 3.5-year medical course; IMA (Indian Medical Association) says the right way to address this is to make compulsory rural health posting of MBBS graduates for one year after internship; and Bihar’s deputy chief minister Sushil Kumar Modi thinks opening a medical college in every district in the state is the proper way to achieve this? In the light of these suggestions, AalaTimes talked with some of the eminent doctors to know their thoughts on the issue.
Dr A K Debdas, associate professor, obstetrics and gynaecology, Jamshedpur Medical College, says, “This is an old disease that the government (not doctors) is suffering for the last 64 years, which I call Paracetamol Psychosis.”
“In a nutshell, this is what the clinical features of this disease is: (Paracetamol here stands for Doctors) Fever – Give Paracetamol – No remission – Give more Paracetamol – If no relief force Paracetamol by injection. Don’t try to find the cause of the fever — whether it is TB, Malaria, Kala-azar, Filaria, Infective Hepatitis etc. Of course, don’t bother to probe into those far-fetched factors — Why TB? Why Malaria? Or why Infective hepatitis? Just try and treat the fever with paracetamol because it is handy, easy to institute,” explains Dr Debdas.
Dr Debdas continues, “Diseases that the poor villagers are suffering from are not due to lack of doctors but due to lack of sanitation, lack of earning/job, lack of education and most importantly lack of roads. Sending a million of doctors will not cure these. It is a mammoth waste of government fund and trained human resource. There is such a lot of overt evidence of the uselessness of blind use of Paracetamol i.e. junior doctors. It is about time the government should think of some effective alternative.”
Responding to the question, why not many qualified doctors are interested in serving in the rural and remote areas of the country, Dr Arunaloke Chakrabarti, professor, department of medical microbiology, PGIMER (Postgraduate Institute of Medical Education and Research), Chandigarh, says, “The reasons are very clear. All of us enjoy town/city life in our young age, except few moralists. Only in advanced age, people get fed up with city life and may go to villages.”
Dr Arunaloke Chakrabarti continues, “Facility in health care set up is very poor in villages, so little scope to do anything. There is not much scope for specialized doctors in villages. There is no scope to earn extra by engaging in private practice after job. There is no good schooling. It is a very important issue. Family, pressure is also an important issue; spouse does not like to stay in village. What’s more the issue of public wrath on doctors when they do not get treatment is another important deterrent.”
Dr S Rajasekaran, chairman, department of orthopaedic and spine surgery, Ganga Hospital, Coimbatore, offers further insights on the issue. According to him, ‘Quality Doctors’ will require ‘Quality Practice Environment’ for practising what has been learnt. “In my opinion, this is an important problem,” he says.
“Whether the patient is in rural area or urban area, the challenges in treatment of a major disease are the same. In fact, it may be more in the rural areas because the patients present usually late in the advanced stages of the disease due to lack of awareness. Many doctors would be attracted to the challenge of treating such complicated cases provided they are offered an environment with good facilities to do so. This is often lacking and is a major cause for reluctance of ‘Quality Doctors’ to settle in rural areas,” says Dr S Rajasekaran.
“There is a great misunderstanding amongst the public that doctors are reluctant to go to rural areas for lack of comfort. While this may be partially true, the bigger truth is that there is nothing more frustrating to see a suffering patient in front of you and you cannot do anything good for them even though you have the skill but the facilities are lacking. If good hospitals are established, it is a fact that many doctors will be willing to serve in rural areas,” adds Dr Rajasekaran.
According to Dr Rajasekaran, the union health minister is addressing only a part of the issue when he advocates a 3.5-year medical course. “Lack of drugs and infrastructure are as serious as lack of personnel. The government has to question itself sincerely on whether it has the funds and infrastructure to support a quality health service in rural areas throughout India. Producing more of less trained doctors with no improvement in infrastructure is not going to produce any tangible benefits to the population,” he says.
Dr Arunaloke Chakrabarti argues that the government’s initiative to develop another cadre for village will not solve the problem; rather it will bring another problem.
Dr Chakrabarti explains, “As per the government proposal these half doctors will not be given MBBS degree and their practice will be limited to the block area. It would never happen that way. Everyone wishes to get the next leap. When these half-doctors become considerable number, they would demand MBBS. Vote politics will force the government to accept. They will be upgraded to MBBS with additional one or two years training. The MCI (Medical Council of India) is no more an independent body. It would be forced to accept them and give license to practice. Then they will leave village and will practice anywhere. So, we will have a new cadre of doctors through back door! There will be conflict of interest in two groups of people (doctors from front door and back door). The crisis of doctors in the villages will remain as it is.”
According to Dr Chakrabarti, even compulsory posting for 1-3 years will also not help. “They would not serve properly during that compulsory period. Moreover frequent change of doctor will not serve good purpose in the village. Developing medical college in every district will also not solve the issue either.”
So, what should be done to address the shortage of qualified doctors in rural India?
“I feel strongly that you have to give incentives to work in villages,” says Dr Chakrabarti. “That can only attract the doctors. Incentives should come as a bundle like postgraduate selection incentive, it can happen in many forms; separate quota in good schools for the children of the doctors working in the village; 50 per cent higher salary while working in the village; better healthcare facilities in the hospitals or centres in the villages; rotation of specialized doctors from city government institutes for one or two years.”
“Beyond all these things, unemployment is slowly entering among the doctors due to too many medical colleges, not much scope in gulf and western countries. This will increasingly push doctors indirectly to go to villages for jobs,” adds Dr Chakrabarti.
Answering the question, Dr S Rajasekaran says, “My opinion may be considered radical but I strongly feel that the solution for the lack of quality doctors in India is because medical education is still vested either with the government or with the MCI approved private colleges. Here we have to adopt the system prevalent in UK and other countries where centres of excellence in different fields of medicine in private sector must be allowed to participate in education.”
“We have a situation where many large private institutions are capable of providing equal if not better educational facilities to the government institutions. These institutions have the cream of the medical profession who are often great teachers but have moved away from government service for lack of facilities to practice what they have learnt. They are often better equipped than their government counterparts. It is a fact that 90 per cent of the health care service in India is provided by the private institutions and not by the government. So, why should we keep medical education away from them,” wonders Dr Rajasekaran.
“The government should harness the capabilities of these private health care institutions and there will be a great scope for more well trained doctors,” says Dr Rajasekaran, adding, “I do not mean diluting the standards in any way. The government must be very strict in setting of standards and the approval of these institutions but must take up the challenge of integrating the capabilities of both the public and private hospitals for the cause of better medical education in India.”
by Rajesh Barnwal