Medical education in India and its discontents

on July 2, 2014July 2, 2014

Book Chapter:Higher studies in India
Dr. Sylvia Karpagam, Edited by Jacob Chacko, February 2014

An indiscriminate inheritance by India of colonial allopathic systems has wreaked havoc on traditional healing systems that have been in existence for centuries. India’s allopathic practitioners have created a monopoly on medical education and healthcare biased towards elitist urban clients. Combined with the pernicious and pervasive caste system against a backdrop of growing neo-liberal commercialization and commodification, this urban monopoly of health care has done nothing for thousands of India’s most vulnerable populations.

In India, during the five years of training that doctors receive, there is hardly any focus on ethics, primary health care or social determinants of health. After undergoing a woefully inadequate Westernised training, the doctor is mostly inexperienced, insensitive and ignorant of many of the larger social and structural issues that are intrinsically linked to health in India. There are many shocking instances of the denial of care, medical negligence, and sexual and physical abuse by health professionals. Many violations by medical professionals leading to gross mental trauma, catastrophic financial expenditure and/or grievous loss of life or functioning of the patient have never been penalized in India.

The Medical councils and health departments refuse to acknowledge these violations and protect their own and the doctors’ interests more than the rights of patients.

For the Rashtriya Uchchatar Shiksha Abhiyan (National Higher Education Mission)[1]to be effective in the domain of medical education, and meet the growing healthcare needs of the country, important issues need to be taken into consideration.

The colonial legacy of healthcare in India

A British or American model of allopathic healthcare is indiscriminately followed by Indian policy makers and readily accepted by teaching colleges, teaching staff, students and even patients. Western textbooks are the primary source of learning and teaching during the five year medical curriculum, at the end of which period, the student is more ready to migrate to a developed country rather than practise in India. Students are trained in tertiary hospitals on allopathic systems of care and are more likely to be able to use expensive equipment to diagnose Western diseases than use clinical skills to diagnose diseases that cause death and disability in India. Physicians trained in India account for 4.9% and 10.9% of American and British physicians respectively with India being the biggest exporter of trained physicians among developed countries. Nearly 54% of AIIMS students who graduated during 1989–2000 now reside outside India.[2]This is a conspicuous form of brain drain which does nothing good for India’s socio-economic development.
In 2004, the Joint Learning Initiative released a report on the potentially harmful effects of the international flow of doctors and nurses on the most marginalized in developing countries, and on the effects of the continuing shift from poorer to richer regions and from the public to private sector.[3]

This is in stark contrast to the Cuban medical internationalism which has provided almost 42,000 workers in international collaboration with 103 countries to provide substantial medical aid and relief to vulnerable communities and populations.

Medical education and health care mired in casteist practices.

Against the backdrop of an active and efficiently functioning caste system in the country itself, it is only natural that these abhorrent practices spill over into medical education and patient care as well.

Institutional casteism manifests itself in several innovative ways. Private medical colleges do not even make a pretence of catering for communities or caste groups that are not socially or economically privileged. Since money and caste are the primary determinants of access to medical education, medical seats are shamelessly laundered to the highest paying bidder. The Indian Medical Association is a farcical regulator and a significant violator of constitutional rights by indiscriminately sanctioning the growing private medical college industry.

Students from marginalized communities face multiple barriers. Inferior primary and secondary education, discrimination during the course period and segregation all take their toll as evidenced by the high rates of suicide by SC/ST(Scheduled Castes / Scheduled Tribes) students pursuing higher education in India. Students are repeatedly detained, forced to undergo humiliating ‘coaching classes’ that only serve to segregate them even further and are often subject to extremely humiliating comments and behaviour from upper caste teachers and fellow students. Redressing of grievances in such cases lacks a moral backbone and is therefore just tokenism.

In 2010, 25 medical students, who had been repeatedly detained, took the Vardhman medical college to the Delhi high court for caste bias. After the court order, a re-exam was conducted and 24 of the 25 students cleared the paper. The National Commission for Scheduled Castes (NCSC) also found discriminatory assessment of answer sheets.[4]
Due to the legal battle, the students had missed several classes and the directorate-general of health services had directed the college to organize extra classes to fulfil the attendance requirement. Nevertheless, despite the court order and the extra classes, the college – having created the problem – claimed the students were “miserably short of attendance”.[4] ”

A report[5]on the allegations of caste discrimination faced by scheduled caste students at Vardhman Medical College, Delhi states that the faculty of the said department “resorted to caste-based discrimination and neglected the duties assigned to them, not by omission but by commission”.

Similar accounts of injustice have emerged from other medical colleges such as the All-India Institute of Medical Sciences (AIIMS) [6] and Lok Nayak Jaiprakash Narayan Hospital[5] (LNJP), showing that that in the five years prior to the enquiry, all the students who had failed the physiology paper belonged to the backward/scheduled castes.
As a stark reminder of the pernicious presence of the caste system, medical colleges have also created ‘colonies’ in the hostels, where SC/ST students are forced to stay.
This discrimination spills over into the recruitment of medical teachers as well. In the All India Institute of Medical Sciences, all norms of reservations have been violated in the appointment of faculty members [i.e., members of the faculty of medicine] with the standard excuse being ‘absence of suitable candidates’. Many ‘reserved’ posts are rather retained as vacant in several premier medical colleges. Prof Pugalendhi, the first ever Dalit to head an orthopaedic department at a government hospital in Tamil Nadu was told by a junior colleague “You are the only untouchable scheduled caste dog and we will see to it that you will be chucked out soon.”[7]

In an attempt to deal with violations in higher education, the United Grants Commission (Prevention of Caste-Based Discrimination/Harassment Victimizationand Promotion of Equality in Higher Educational Institutions) Regulation was brought out in 2012[8]. It takes cognizance of several overt and covert methods of harassment and victimization of Schedule caste/Schedule tribe (SC/ST) students by their teachers and peers. These recognized injustices include biased evaluation of exam papers by professors by giving lower marks to SC/ST students, passing derogatory remarks indicating caste as a reason for under-performance in class, keeping such students idle in the laband not allowing them to work, segregating such students from others in hostels/messes/reading rooms, etc; acts of ragging specifically targeting these students and non-implementation of the reservation policy for admissions.The 2012 Regulation has not yet been implemented: it is a dead letter, another piece of tokenism.

The evidence of research shows that poor health outcomes – malnutrition, maternal deaths, morbidity and mortality due to acute infectious diseases are much higher among Dalit women. In an article ‘Caste and inequalities in health’ in The Hindu, August 22 2009, Prof K.S. Jacob categorically dissects the influence of caste in every aspect of health care delivery and states that the system, generally identified with Hinduism, is also prevalent among Christians, Sikhs and Muslims.[9]

The body of a woman during menstruation and pregnancy is considered polluted. This means that many medical professionals cringe at the thought of contact with body fluids. Dalit women, who are at the bottom of the caste, class and gender hierarchies, suffer multiple levels of caste discrimination by the health systems ranging from denial of care, harassment, verbal and physical abuse, avoidance of physical contact and negligence. This violates the right to life guaranteed to the citizens of the country under Article 21 of the Constitution of India, Para 39.

Neglect of the social determinants of health

The World Health Organization (WHO)[10] has defined social determinants of health as the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries.
In India, however, there is a conspiracy of silence in medical colleges about the social determinants of health and most medical students, who are derived from privileged backgrounds, will be unable to provide any  dialogue on aspects of social justice that determine health of individuals, the community or the country. During their training period, medical students are directly linked with tertiary services and are shockingly ignorant about the existence of poverty, inequity, discrimination and psychological abuse faced by millions of people on a day to day basis. Textbooks are useless to sensitize medical students about their role as healers and change agents in society.

Medical education glosses over the specific health issues faced by marginalized communities like the Tribals, manual scavengers, child labourers, agricultural labourers, plantation workers, those working with hazardous material (e.g., ship breakers in contact with asbestos)and others in the unorganized sectors. Many teachers of medicine often pass on their own sexist, casteist and elitist biases and prejudices to their students.
PricewaterhouseCoopers in 2007[11) analysed healthcare in India as an ‘emerging market’ in terms of revenue and employment. It estimated the value of the health sector in India to be $40 billion in 2012 translating to more than 6% of the GDP. Pricewaterhouse proudly state that a Google search for ‘India medical tourism’ throws up more than two million results showing that the country’s ‘well-educated, English speaking medical staff, state of the art private hospitals and diagnostic facilities costing less than 1/10thof the bill incurred in the US. This industry alone was estimated to reach $2 billion in 2012.

To encourage the growth of medical tourism, the government is also supporting a’medi-city’ on 43 acres of land in Gurgaon, Delhi at an estimated cost of $493 million. This is apart from the lower import duties, higher depreciation rates on medical equipment and expedited visas for overseas patients. The economic policy behind this reflects the same injustice as the actual state of medical services in India for India’s people.

The medical education in India is, therefore, geared to providing state of the art care to international medical tourists while the majority of its citizens face catastrophic health situations without any sign of respite from the government or medical professionals.
India’s commitment to primary health care lies in ruins

India was a signatory at the first international conference on Primary Health Care at Alma Ata, Kazakhstan in 1978[12]which called for an urgent and concerted effort by governments and the world community to protect and promote the health of all people.

In the declaration, primary health care (PHC) is defined as “essential health care based on practical, scientifically sound and socially acceptable methods and technology, made universally accessible to individuals and families in the community. It is through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination”. PHC includes all areas that play a role in health, such as access to health services, environment and lifestyle.

WHO published its recommendations on “Reorienting medical education” (ROME) in 1991, arguing for major shifts in the educational model[13]. Yet, two decades after the proposal, the changes made have been minimal and superficial; training continues to be inappropriate and inadequate for meeting the health needs of India.

Although prevention is clearly the most effective and cheapest way of fighting ill health and reducing the high cost of secondary and tertiary care, it means that the medical profession would stand to lose financially if India’s preventive services were extremely good. The highly lucrative, complex and expensive treatments offered at secondary and tertiary care become a good incentive for market forces to ignore the preventive and primary component of healthcare. A patient educated about the ill-effects of smoking and supported to quit or reduce, is less lucrative to the health market than a terminally ill lung cancer patient requiring extensive lung resection surgeries and respiratory support.

Unscrupulous market agencies have converted health into a commodity that must exist for the market to survive. Ill-health therefore becomes an incentive for the private player; the more illness, the better, because the profits rise. Ill-health is therefore propagated and people become victims of the curative syndrome where they believe that they need to be cured to be healthy

In India the health chapter of the Planning Commission[14] is a clear indication that policies are moving away from comprehensive primary health care to a curative model that enriches the tertiary private sector.

Privatization of medical education and health policy making

The booming private sector healthcare industry in India is shameless proof of the government’s neo-liberalism that has wreaked havoc on public services and the health of millions of its citizens. Doctors who graduate from private or government medical colleges are absorbed with enthusiasm by private hospitals that are getting more specialized, more exorbitant and more numerous – all in the absence of even a pretence of regulation.
According to the Jan Swasthya Abhiyan (JSA) in 1950 there were 60,000 MBBS doctors; today, there are 7.5 lakh MBBS, an equal number of AYUSH doctors, and most of them are private providers. Added to this is the tremendous growth of corporate hospitals, starting with the Apollo Hospital in Chennai in 1983. India’s neo-liberal, consumerist economic policy has fuelled the growth of corporate health care from the1990s. The JSA has made known widely that, during 2003-2008, sales of 30 companies in the healthcare sector have galloped. For example, those of Apollo Hospitals Enterprise Limited increased from Rs 500 crores to Rs 1458 crores in this period. In 2008, the income of Apollo Hospital alone was Rs. 1150 crores, 28% more than the previous year’s and profits were 102 crores, 51% more than in the previous year.

The unrestrained and unscrupulous marketeering by the private medical sector has led to unabashed violations in India. Patients are treated purely on their ability to pay bills running up to lakhs of rupees. The pharmaceuticals, equipment, biomedical and research industries have jumped into this growth marketto extract a sick patient’s minimal resources. Healthcare is the primary cause of catastrophic health expenditure in India. The few bodies, if any, to regulate these profiteers are inefficient, corrupt and dysfunctional.
The CABE Committee on Higher Education funding, which submitted its report in 2005, stated- “… reduction in state funding for higher education, corresponding cost recovery measures and rapid growth in privatization of higher education – all begin to produce serious problems on access, quality, equity and efficiency in higher education.”

The Kothari Commission[15] has stated that education should be supported by government and not private funds and that fees were the most regressive form of taxation that disproportionately affected poorer classes. The Kothari Commission found that the then existing levels of fee contributions were much higher in India than in the educationally advanced and richer counter such as the US and UK.

The Central Bureau of Investigation (CBI) arrested[16]the president of the Medical Council of India in 2010 for accepting bribes to grant recognition to a medical college and being in possession of disproportionate assets worth Rs. 24 crores.

Although the Prohibition of Unfair Practices in Technical Educational Institutions, Medical Educational Institutions and University Act, 2010has been welcomed by the different states, there has been no implementation of its provisions and principles.

India is also a hotspot for biomedical research and clinical trials, usuallyoverseen by medical doctors. Pricewaterhouse Cooper[11]have observed – in 2007 – that “the huge patient population in India offers vast genetic diversity, making the country an ideal site for clinical trials. It has the largest pool of diabetic patients, the population is relatively easy to access, and many people are ‘treatment-naïve’; they have not been treated with medications being tested, which potentially could distort test results. As a result of these favourable factors, the Indian clinical trials market, currently estimated at $120 million, is expected to reach $1 billion by 2010. To achieve that level of growth, India will have to address a lack of skilled workers, high wage inflation, and inadequate infrastructure. For western companies that can navigate these obstacles, the rewards will be substantial”
The spate of clinical trials and biomedical research in India over the last decade has been largely unregulated and unscrupulous.It is as if human beings are being treated as laboratory animals.

A recent case[17] that hit the headlines was the field testing in 2010 of HPV vaccines by Program for Appropriate Technology in Health (PATH), a non-profit organization based in Seattle and funded by the Bill and Melinda Gates Foundation. The study involved vaccinating 13,000 Tribal school girls aged 10–14 in Khamma district, Andhra Pradesh with Gardasil and 10,000 with Cervarix in Vadodara, Gujarat. The study was initially intended to run until 2011, but the Indian government halted the trials in March 2010 after activist groups, opposed to the introduction of the vaccine in India, alleged safety and ethical violations following the death of seven girls enrolled in the study. In Andhra Pradesh, only 1,948 of the 9,543 consent forms had thumb impressions while the rest had been signed by the hostel wardens. .

The Parliamentary Standing Committee on Health and Family Welfare has accused PATH of exploiting with impunity the loopholes in the system and has also questioned the roles of the Indian Council of Medical Research and the Drug Controller-General of India, in promoting the interests of vaccine manufacturers.

Nationalization of medical education and healthcare – a way forward
If India truly wants medical education to be responsive to the pressing and alarming healthcare needs of its citizens, there is a need to re-examine the entire system of medical education and healthcare in India.

Medical education needs to move away from the expert and medical domain to develop responsive, committed and socially concerned doctors and other personnel. Common health problems should be treated at the primary care level with super-specialities, and tertiary care should be provided only for the smaller proportions of patients who actually need these services.

Nationalization is the process of taking all corporate and private health care providers into public ownership by a national government or state.

India has many good examples to learn from.

The Cuban model of nationalized healthcare[18] has received wide acclaim and by any standards, Cubans are among the healthiest peo¬ple in the world. The health outcomes rival those of far more eco¬nomically and technologically advanced countries and are produced at a fraction of the cost. Life expectancy at birth is 78, IMR is 9.5, MMR is 73 and low birth weight 5%.The private expenditure on health as a percentage of total expenditure on health is 5.3 in Cuba. There is a three tier system – primary, secondary, and tertiary. The primary care level is responsible for health promotion and treatment of 80% of the disease burden through clinics and polyclinics as well as homes of patients. At the secondary care level, care is designed to handle the 15 percent of health problems that result in patient hospitalization. The tertiary care is designed to treat the remaining five percent of health problems – situations where illness has resulted in severe complica¬tions.

Following the revolution in 1959, Cuba began to revamp the focus of medical services towards preventive medicine and also training of health professionals towards comprehensive primary healthcare and seamless integration of the family and community. The Cuban model proves that political will can provide a responsive health care system that meets the needs of all citizens and also provide aid and training to many of the poorest nations of the world.

The Cuban model follows, in practice and principle, the guidelines laid down at Alma-Ata in 1978. The focus is on primary health care and training of family practitioners. The Cuban system is geared to integrate curative care with public health and prevention of disease. In 1976, oversight of medical education was transferred to the Ministry of Public Health to make these changes effective at all levels. By 2009, Cuba had 74,880 physicians, or one doctor for every 150 citizens, compared to one for every 330 in Western Europe, and one for every 417 in the United States.

With the establishment of the family doctor-and-nurse program, the general medical curriculum was changed to fit the family doctor model. Cuba has made a big impact on the world of vaccines and hi-tech drugs and has entered into production agreements with many foreign partners.

The Cuban model has received the praise of competent assessors. Dr Halfdan Mahler, former director of WHO, said in 2000:No other country has been as consistent in taking measures towards achieving the goal of “Health for All” as Cuba.[18]

In the words of Dr Patrick Dely, a Haitian graduate of La Escuela Latino americana de Medicina (ELAM), Cuba “I began to realize that I was already very privileged, since I had been permitted to get a good education in an honorable career, and that I didn’t need any more privileges. A new philosophy began taking shape in my mind. I began dreaming big, beyond just being a doctor for me. I started thinking about my country, and thinking about others. I started to feel a responsibility to help as many people as possible.”[18]

For, as Che Guevara states in On Revolutionary Medicine, 1960:
Often we need to change our concepts, not only the general concepts, the social or philosophical ones, but also sometimes our medical concepts. [18]

Reference:

[1] “Rashtriya Uchchatar Shiksha Abhiyan – National Higher Education Mission, Ministry of Human Resource Development in association with the Tata Institute of Social Sciences,” no. September. 2013.
[2] M. Kaushik, A. Jaiswal, N. Shah, and & A. Mahal, “High-end physician migration from India,” Bull. World Health Organ., vol. 86, no. 1, pp. 40–45, Jan. 2008.
[3] “Human Resources for Health Overcoming the crisis, Joint Learning Initiative, Global Equity Initiative, Harvard University,” 2004.
[4] N. Chandra, “SC students of city medical college allege caste bias behind repeated failures in examinations,” India Today, New Delhi.
[5] S. Gatade, “Dronacharyas all: Caste discrimination in higher education,” Infochange, Human rights, Oct-2012.
[6] “Thorat Committee Report: Caste Discrimination in AIIMS,” Econ. Polit. Wkly., vol. Vol – XLII.
[7] DNA Correspondent, “In the birthplace of self-respect movement, Dalits fight for their dignity,” DNA, 15-May-2012.
[8] R. Chopra, “University Grants Commission bars caste bias in campus,” India Today, 04-Jun-2012.
[9] K. Jacob, “Caste and inequalities in health,” The Hindu, 22-Aug-2009.
[10] “Closing the gap in a generation: Health equity through action on the social determinants of health,Commission on Social determinants of health, World Health Organisation,” 2008.
[11] Pricewaterhouse Coopers, “Healthcare in India: Emerging market report,” Pricewaterhouse Coopers, 2007.
[12] Declaration of Alma-Ata International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978, no. September 1978. 1978.
[13] “Reorientation of medical education and medical practice for health for all, (Twelfth plenary meeting, 12 May 1995 – Committee A, second report) Hbk Res., Vol. III (3rd ed.), 1.8.” 1995.
[14] “Twelfth Five Year Plan (2012–2017), Planning Commission of India, Government of India,” vol. III, 2012.
[15] D. Kothari, “Education and National development: Report of the education commission, 1964-66, National Council of Educational Research and Training,” 1966.
[16] “Medical council president arrested on bribery charges,” Indian Express, 20-Apr-2010.
[17] A. Dhar, “It’s a PATH of violations, all the way to vaccine trials: House panel,” 02-Sep-2013.
[18] S. BROUWER, Revolutionary doctors: How Venezuela and Cuba Are Changing the World’s Conception of Health Care, vol. 83, no. 12. 2011, pp. 331–4.

 

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