In June last year, ward boys and sweepers in a hospital in Uttar Pradesh were found stitching up wounds and administering injections to patients. In the media outrage that followed, one important fact was drowned out. Thousands of vacancies for rural doctors in India remain unfilled. Without enough hands on deck, overburdened doctors in decrepit hospitals need other less qualified employees to pick up valuable paramedical skills. The ward boys and sweepers, in this case, had been doing similar work for at least a decade. And saving lives.
In May this year, the Health Ministry wrote to the Medical Council of India (MCI) asking that rural posting for doctors be made mandatory. The MCI is the central body that, among other things, governs medical education in the country.
In August, the MCI finally bowed to the government demand and amended its Postgraduate Medical Education Regulations. Medical students must now spend at least one year working in a rural hospital after getting an undergraduate (UG) MBBS degree. They will be eligible to sit for entrance exams for a postgraduate (PG) course only after this one-year stint. Students who aren’t interested in a PG course are still free to practice medicine independently.
On August 8, 2013 medical students in New Delhi took to the streets to protest this new rule. They faced down water cannons and baton charges. Perhaps there was a tiny thrill of defying authority, but their concerns are real. A delegation met health ministry officials, who offered a sympathetic ear – but no solutions.
There is still not much clarity about why these students were enraged by the idea of a rural posting. For example, in Andhra Pradesh government has asked its postgraduate medical students to retroactively serve the one-year rural stint, which has led the state’s postgraduates to protest as well. They are unwilling to work as general practitioners and do work that could be done by an undergraduate MBBS student. In return for a year of rural service, they are demanding permanent government jobs and salaries. Just one example of the minefield that medical regulation in India can be. Where does that leave our rural health care?
Let’s backtrack. An undergraduate medical course in India, till recently, lasted 5.5 years with the last year dedicated to an internship. With the new rule, a follow-up year of service in a village effectively increases that duration to 6.5 years before you can take a shot at a PG course. Minister of Health and Family Welfare Ghulam Nabi Azad has defended this new apparent imposition. It takes 7 years or more to become a doctor who can prescribe medicines in the West, he has argued. Even after an extra year of service, the Indian training is shorter and much more cost effective than similar options abroad.
However, to many young students, an extra year in a village seems like a death sentence. One of the reasons is because of their humungous monetary burdens. Medical education in government colleges is highly subsidised, costing anywhere between Rs 10,000 – 75,000 per year. But with just 15,000 government seats on offer every year, thousands flock to private medical colleges.
A merit seat in a private college can cost anywhere between Rs 10 – 30 lakh per year. But many prefer to simply buy a seat from the college management’s discretionary quota – which means an investment of Rs 50 lakh – Rs 1 crore. India is the only country in the world to permit such a sale of medical seats, Sujatha Rao, former Secretary, Ministry of Health & Family Welfare, recently argued.
Most families take enormous loans to finance a medical education. This is a risky gamble since a plain MBBS degree doesn’t pull in big salaries anymore. Those go to doctors with specialized skills. To thousands of new doctors, the way out of their debt burden is through high-paying jobs abroad after getting an education in India. Any delay in this carefully structured race can mean delayed employability, lower salaries and soaring loan repayment costs.
One solution would be to increase the number of subsidized seats. However, regulatory hurdles have ensured that new medical colleges can’t come up easily, limiting the number of seats available. In a nation of 1.2 billion people, only about 46,500 students (private and government combined) are admitted annually to India’s gruelling undergraduate medical programmes. About 40,000 graduate with an MBBS degree every year. Most intern at hospitals while studying intensively for their postgraduate exams. That’s when they run into a wall.
Only 22,000 postgraduate seats are up for grabs in India annually (both government and private combined). Of those, a mere 12,000 are in streams where doctors interact intensively with patients – like surgery, gynaecology, paediatrics and obstetrics. These are the streams that most doctors compete for. In the unified postgraduate entrance exam held across India in 2012, roughly 1 lakh doctors, both freshly graduated and from older batches, fought for those 12,000 seats.
Dr Navneet Motreja and Dr Nithya Nagesh are both graduates from MS Ramaiah medical college in Bangalore. Motreja graduated in 2012, Nagesh in 2013. While preparing for their postgraduate exams, both realized the odds were stacked against them – a shortage of seats was leading many of their seniors, despite years of effort, to be shut out from medical streams they really wanted to pursue. After talking to a number of veterans for almost a year, Motreya and Nagesh launched the Save the Doctor campaign on July 29, 2013. The idea is to petition the government to raise the number of postgraduate seats in medical colleges.
“Increasing the number of PG seats need not take years or crores in investment. It simply needs a policy change,” says Dr Motreja. “The current government guidelines say one professor is supposed to teach only one PG student per year. If you tweak the guidelines and allow two or three students to train under a single professor, it will not dilute the quality of training. But it will immediately double or triple the number of PG seats available. It’s that simple.”
Motreja and Nagesh certainly don’t sound like spoilt urban brats. They say they are not against doctors serving in rural areas – they just don’t want an extra year of service added arbitrarily. Motreja says, “Doctors spend up to 13 years studying, first for an undergraduate degree and then for post graduation, and then for specialization. Instead of a year of rural service at one stretch, wedged between your UG and PG degrees – why not break up the service into four parts of three months each? You [could] spend three months every year in a village – in the last year of your MBBS and every year for the three years of your PG course. That [would] ensure you have enough doctors working in the villages. And it [also] ensures those doctors get their degrees on time.”
It isn’t only young doctors who are proposing a different way of solving the current crisis. Dr Devi Shetty is founder and chairman of Narayana Hrudayalaya, a multi-speciality hospital near Bangalore that also treats poor patients at extremely subsidized costs. He is also treasurer of the Association of Healthcare Providers of India (AHPI), one of the organisations that support the Save the Doctor campaign. His weighing in on the side of young medical students has lent credibility to their campaign. The Indian Medical Association (IMA) also supports the campaign – its General Secretary, Dr Narendra Saini says, “Don’t impose rural service on the students. Make it voluntary but give them incentives for the work like extra credits during PG exams.”
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Apart from the problems of finances and logistics, there is also some truth to the perception that young city-trained doctors are terrified by the actual daily challenges of working in a village. Even in urban settings, freshly minted doctors fret after their MBBS that they are not competent enough to treat patients without supervision. Some say they worry that if a patient dies in a rural setting, they will face violence from local communities. They complain about the lack of security, proper accommodation and a complete lack of diagnostic equipment and basic infrastructure in rural hospitals.
Doctors who have worked for decades in rural India challenge these assumptions. “Young doctors should know that the only people who even Naxals don’t attack in our most interior villages are doctors. They value their service too much,” says K Sujatha Rao, Former Secretary of Health and Family Welfare, Government of India. She adds bracingly, “Of course, infrastructure is weak in rural India. But not all problems require fancy infrastructure. Some of the biggest causes of fatalities in rural India are diarrhoea and malnutrition. You want a lab to diagnose that? You’ll be treating colds and coughs, back and body aches, sprains, wounds and cuts. You’ll be delivering babies or treating malaria. Sure, you’ll be investigating TB, doing a few appendix operations. Those require advanced equipment. But 80 percent of the ailments can be taken care of in the village,” she argues.
Dr KR Antony was a former Health & Nutrition Specialist for UNICEF and former Director of the State Health Resource Centre in Chhattisgarh, one of the poorest states in India. He is also an alumni of St John’s Medical College in Bangalore and was the first student in his batch to volunteer for a rural posting. St John’s Medical has, for decades, insisted that students sign a bond when getting admission – it binds all students to two years of work in rural villages before they become eligible for a degree. In all these years, says Dr Antony, the students haven’t faced any impossible problems. “If you work with love and sincerity, no one is going to eat you up alive. Sure, they might challenge you if they think you’ve made a mistake. But you’ll face serious problems only if you’re haughty and arrogant,” he says. “Women doctors would sometimes be summoned in the middle of the night to attend to emergencies. There would be local drunks lolling around. But the women of the village would shoo them off. They would protect them with their lives – that’s how much they loved those doctors.”
Augustine Veliath, a health communication specialist formerly with UNICEF in India, joins him in these cheerful reminiscences. “These students take subsidized education from government colleges,” he says, “And at the first instance, they jump to greener pastures abroad. Nobody’s telling them not to go. All the government is saying is: give something back to society. To the poor of this nation. Sure, it’ll be tough. But they’re young. And this is an adventure. I’m surprised these young people can’t see that.”
Curiously, some of India’s best-known rural doctors sympathize with the fears that today’s urban generation has about villages. Dr Mira Shiva in Delhi helps coordinate a loosely knit network of rural doctors, called the Medico Friends Circle. You’d expect her to be glad that the government is finally sending reinforcements to the villages. Instead, she’s pretty caustic about it: “If you think that suddenly nudging all these fresh doctors into villages is going to solve all our problems, you’re mistaken. Sure, there might be some political mileage to be made. But this is not a magic bullet. It’s merely a start.
“These kids will have a hard time coping, because nothing they’ve learnt so far prepares them for cases in real life. They don’t know anything about indigenous medicines, which are often the cheapest, most effective lifesavers available in a village. They don’t know how the system works. So even if their medical centre is entitled to a supply of free allopathic medicines from the state, they wouldn’t know who to ask for them.
“They have no gender sensitization which means, often, they shy away from asking a female patient if she is pregnant or not. Some medicines, if prescribed during pregnancy, can cause birth defects. They might treat a patient for malaria but after a few days of improvement, patients don’t come back – because no one told them that malaria antibiotics have to be taken for their full course. They see villagers die of diarrhoea – because no one told them that a simple water, sugar and salt solution could keep them alive. These experiences can be frustrating and nerve-wracking for a newcomer.”
Dr Binayak studied at the Christian Medical College in Vellore, Tamil Nadu. He and his academic wife Ilina Sen have worked for over three decades in rural India. They gave up lucrative careers to take care of mine workers deep inside southern Chhattisgarh. With government contributions few and far between, the couple helped 10,000 workers pool their earnings to build Shaheed Hospital in Chhattisgarh, which is still running today. The couple also taught Adivasis paramedical skills – those Adivasis now run their own health centre.
“We were from a different time,” explains Dr Ilina Sen. “Born before Independence, we had some of that nationalistic fervour. We’d never seen much luxury so its absence didn’t perturb us much. Kids today have seen a lot more prosperity; they assume that is the norm. When they come to the interior, the contrast can be scary. We must ask ourselves why, after 66 years of independence, rural India is in such a shambles. Buildings built for the expensive National Rural Health Mission stand derelict. The nearest referral facility, if you need a diagnosis, is at least 50 km away. Forget transport and electricity and security. Doctors who wants to settle and work here won’t find a half-decent school to send their children to. At some point, it begins to hurt.”
While the Sens are a famous example of outstanding rural medical service, they aren’t the only ones. In Maharashtra, Dr Rajnikant and Mabelle Arole, Dr Abhay and Rani Bang, Dr Ashok Dayal Chand and Dr Anant Phatke; in Karnataka, Dr Ravi and Thelma Narayan; in Assam, Dr Sunil Kaul; in Rajasthan, Dr Samit Sharma. All across India, many doctors have been working tirelessly in mission hospitals and public and community health centres. They work not for the money but for the satisfaction of making a difference to people’s lives.
India’s rural health crisis is not merely about a shortage of doctors, points out Dr Shiva. There is a shortage of everything – medicines, technicians, equipment, blood banks, ambulances. The education syllabus itself is skewed without any specific rural health training. More troublingly, the entire system is focused only on curing problems. There is no attempt to provide comprehensive health care and little training on how to prevent diseases, promote health or rehabilitate patients.
To give the government something to think about, young medical students plan to march again in the streets of Delhi on Monday, 26th August. Students in five other cities – Mumbai, Bangalore, Hyderabad, Jaipur and Hissar – will also join in the protest at 4 pm. According to the Save the Doctor campaign website, more than 2 lakh students have already expressed support for their cause.
What happens if neither side blinks, I ask Sujatha Rao, who used to be Secretary, Ministry of Health & Family Welfare. She sighs. “This issue of compulsory rural service has been bandied about ever since I entered the ministry in the 1990s,” she says. “On multiple occasions, the government has hinted at the move. Then the doctors sweet-talk a few politicians and the whole issue is neatly swept under the carpet. This time, I really hope the government stands firm.”
Jaimon Joseph is a multimedia journalist who reports on science, technology, defence and international affairs. Follow him at https://twitter.com/jaithemon