|SPEAKING FOR MYSELF
|Year : 2020 | Volume
| Issue : 2 | Page : 113-116
When will we function effectively for the benefit of our country?
Sunil K Pandya
Department of Neurosurgery, Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India
|Date of Submission||24-Sep-2020|
|Date of Decision||05-Oct-2020|
|Date of Acceptance||06-Oct-2020|
|Date of Web Publication||15-Dec-2020|
Dr. Sunil K Pandya
Department of Neurosurgery, Jaslok Hospital and Research Centre, Dr. G. V. Deshmukh Marg, Mumbai - 400 026, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Pandya SK. When will we function effectively for the benefit of our country?. J Med Evid 2020;1:113-6
Our profession has, as its raison d'être, the prevention and treatment of disease. These tasks involve a wide range of disciplines – medicine, education, the humanities, ethics, law, social service, economics and even politics.
| Politics|| |
This is a topic seldom discussed in medical journals.
Albert Camus' statement in 1963 might as well have been describing the current state in India: 'Politics and the fate of mankind are formed by men without ideals and without greatness. Those who have greatness within them do not go in for politics'. Ronald Reagan was more forthright: 'Politics is supposed to be the second oldest profession. I have come to realize that it bears a very close resemblance to the first'.
Not only is this true in seeking entry into legislative assemblies or the houses of parliament but also into medical councils in the states and in New Delhi, the centres of power in medical associations and in such bodies as universities – which were once hallowed centres of learning.
The few who hope to reform the systems from within soon learnt to their dismay that entry and rise to positions where policies and procedures can be influenced is impossible unless one is willing to run with the hellhounds driven by greed for pelf and power.
Honest, humane and ethical individuals find it difficult to dislodge those already firmly entrenched in what ought to be responsible bodies and agencies.
It need not be so.
Ancient physicians were renowned for their exhibition of agape. To them, this term represented the highest form of love and charity. It sought the best for others. This lofty goal of yesteryear and the 'goodness of the physician' (Hippocrates) have all but vanished, having been substituted by an insatiable need to set themselves up as false gods.
To state that corrective measures are desperately needed is to underline the obvious. In the final reckoning, these boil down to the awakening of the consciences of all those working in the health sciences, the burgeoning of the urge to irrevocably change extant measures and practices for the better and the development of a cadre of leaders with courage and perspicacity.
We must redefine politics in the terms used by Bismarck: 'Politics, at its best, is the art of the possible and the leaders in this field are defined by their expertise in overcoming difficulties and enabling whatever is needed for the common good'.
The cream of our profession must be empowered to attain high and potent positions in bodies that govern the welfare of our people and direct policies that address housing, education, health, sanitation and means for earning honest livelihoods for all our citizens. This had happened soon after independence and there is no reason why it cannot be made the norm again.
Equally important, even before the goals in the preceding paragraph have been attained, we must dissociate institutions such as the universities, colleges, research laboratories and institutes and medical councils from the machinations of politicians and government. These bodies, vital to the public weal, must be helmed by individuals of impeccable integrity and helped to grow into centres that will attract the best brains not only in our country but also from those such as America, Britain, Canada and Australia where they have hitherto been drained.
| Healthcare|| |
For far too long have we ignored Gandhiji's vision of healthy villages. The heart of India beats in them. If they fester through long-term neglect or indifference and be plagued by illiteracy, sickness and their consequences, the rest of India must also suffer. This was made evident during the COVID-19 lockdowns when hundreds of thousands trekked back to their villages under inhuman conditions and left metropolitan centres nearly paralysed.
Universal access to healthcare via an organised system of social welfare has been internationally accepted as the ideal. The experiment initiated by Mr. Aneurin Bevan in Britain has, despite its ups and downs and current domination by 'managers', yielded dividends. Bevan, himself, is a model for each of us. In a letter written by Jennie Lee to Michael Foot on 7 July 1960 – the day after Bevan's death– she described him thus: 'He was not a cold-blooded rationalist. He was no calculating machine. He was a great humanist whose religion lay in loving his fellow men and trying to serve them.'.
A national health service providing free and subsidised medical care of high quality, drugs, appliances, home care, transport to and fro health centres and well-established and streamlined three-tier system with efficient flow of patients from primary to tertiary centres and vice versa needs funds, time, effort and dedication. Should it actually come into being, however, the benefits to our poorest citizens will be incalculable.
The present situation where already weakened villagers carry their sick relatives on their backs or on makeshift and bone-rattling transport to ill-equipped and often unattended primary health centres is an abomination.
The need for healthcare in villages and the fact that it can be provided have been proven in several? oases where non-governmental organisations manned by selfless and highly motivated workers have worked wonders.
We need to duplicate and if possible improve on their results in every village in the remotest corners of our country.
| Our Progressive Watering Down of the Bhore Committee Recommendations (1946) and the Alma Ata Declaration (1978)|| |
The committee headed by Sir Joseph Bhore enunciated in 1946 the unchallengeable principle that nobody should be denied access to health services for his inability to pay. It also focussed on rural areas.
Even so, the first primary health centres were set up only in 1952. The goals were lofty: provision of integrated promotive, preventive, curative and rehabilitative services to the entire rural population. It also included a national programme on family planning.
September 1978 saw the emergence of the declaration of the International Conference on Primary Health Care at Alma Ata in the U.S.S.R. The conference
'strongly reaffirms that health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector…
The existing gross inequality in the health status of the people, particularly between developed and developing countries as well as within countries is politically, socially and economically unacceptable and is, therefore, of common concern to all countries.
…The promotion and protection of the health of the people is essential to sustained economic and social development and contributes to a better quality of life and to world peace…
The people have the right and duty to participate individually and collectively in the planning and implementation of their health care…'
India was a signatory to the Alma Ata Declaration that assured 'health for all' by the year 2000.
Both these far-sighted documents have been watered down and then dismantled. They have been termed unrealistic and expensive. The development of rural communities and their participation in all matters concerning them gave way to privatisation and 'liberalisation' such that politicians and the private sector came to dominate medical education, healthcare, clinics and hospitals. Is there any cure against these despicable trends?
An assembly of 1453 participants from 92 countries have drawn up People's Charter for Health in 2008. This document deserves study and must prompt wide action.
| Medical Education|| |
Concurrent with the dismantling of effective healthcare for the poor has been the demolition of the carefully laid down and developed system of medical education. From the 1830s, medical colleges were developed by governments in Calcutta, Madras and Bombay. Over the subsequent 120 years, these and other colleges in cities such as Agra, Lahore, Patna, Dhaka, Cuttack, Poona and Indore, modelled on the first three colleges, performed well. Patients were treated using the highest standards of medical care in the hospitals attached to them. Graduates from these colleges fanned out through the respective provinces and states and created a network of modern medical care.
These colleges and their graduates were respected not only in India but also throughout the British Commonwealth.
Universities in Calcutta, Madras and Bombay were set up in 1860. The lists of their early fellows, vice chancellors and other officials included the intelligentsia of the times. In Bombay, Kashinath TrimbakTelang, Ramkrishna Gopal Bhandarkar, N. G. Chandavarkar, Pherozeshah Mehta, R. P. Paranjpe, Justice Mirza Ali Akbar Khan, John Matthai and V. R. Khanolkar were some of those who adorned these positions.
The system of medical education has been bedevilled since the 1960s by a series of retrogressive steps:
- The setting up of 'for-profit capitation fee medical colleges'. The evils of this system are well known. Corruption in the Medical Council of India, substandard teaching staff, transient patients imported to fill hospital beds when inspection by regulatory agencies is due and the huge sums to be paid by those wishing to be admitted as medical students are just some examples. Such a system could not have been set up and allowed to flourish as it does without the blessings of those in power in governments.
- Systematic downgrading of public sector medical colleges. This was necessary to enable private-sector colleges to flourish and steps to achieve this goal have been taken deliberately and with disastrous efficacy.
- The degradation of universities occurred pari passu. Universities such as those in Calcutta, Madras, Bombay and Allahabad, which had provided praiseworthy services to the community over decades, were infiltrated by political appointees. Vice chancellors were now appointed on the basis of patronage instead of sterling merit. Corruption flourished. The system of evaluating the academic competence of those aspiring to obtain medical degrees degenerated. The creation of 'medical universities' multiplied the opportunities available to politicians and those willing to cater to their needs. Teaching, the care of patients and research – prime functions of medical colleges – were allowed to decay. The emphasis on regional and local languages in medical education in preference to English, the admission to medical colleges of students who had failed to prove their merit at tests and at the expense of those who had, merely on the basis of their status in communities, played no small role in this rot. The number of private universities in India is 361 as against 465 state and central universities.
- 'Deemed university'. By definition, this is an award by the Department of Higher Education, under the Ministry of Education. 'An Institution of Higher Education, other than universities, working at a very high standard in specific area of study, can be declared by the Central Government on the advice of the University Grants Commission (UGC), as an Institution Deemed-to-be-university. Institutions that are deemed-to-be-university enjoy the academic status and privileges of a university.' The advantages to them are many. They are autonomous and answerable to no higher institute of learning. In a country where, at the best of times, monitoring is riddled with problems, many wonder how the standards at these universities will be evaluated and when found below par, corrected. The number of 'deemed universities' on 4 August 2020 was 124.
The list of deemed universities provided at https://www.ugc.ac.in/oldpdf/Consolidated%20list%20of%20All%20Universities.pdf makes interesting reading. A study of the medical institutes listed, aimed at learning the 'very high standard in specific area of study' at most of these universities is a sobering venture. The experience will make you wonder on the true reason many of these institutes were labelled thus.
- The matter of reservations. There can be no debate on the manner in which, over centuries, 'higher castes' have lorded it over those they deemed to be of lower significance.
Dr. B. R. Ambedkar et al. who formulated our constitution recognised this and provided for the upliftment of the many who had hitherto been subjected to atrocities and humiliations.
In their wisdom, they recognised that such provisions had to be time bound, after which continued favours would prove counterproductive. The generation of self-respect, the urge to excel and compete and attainment of positions of eminence on merit were the eventual goals. Thus, and only thus, would these hitherto severely downtrodden members of our society be able to hold their heads erect and participate as equal members of society.
The responsibility for these changes rested on governments in Delhi and in the states. It is a sad fact that it was easier for these governments to continue to pay lip service to the upliftment of the poor and deprived even as they turned a blind eye to the depredations of the 'upper castes'. Thus, it has come to pass that we now have reservations for a variety of scheduled tribes and castes at every stage. Of concern to us is the huge percentage of reservations based on caste in admissions to medical colleges and when appointments are made from the level of lecturers to professors, deans and directors of institutes.
Such reservations favour admission and selection of those with little merit over those with outstanding evidence of proficiency. This step has, inevitably, led to a progressive fall in standards with obvious deterioration in teaching, medical care and research.
| What is the Cure?|| |
Given the undisputed fact that poverty and discrimination continue to plague large segments of our population, it makes eminent sense to provide nutrition, sanitation, education and other necessary facilities from birth onwards to the poor and deprived. This will require massive, continued improvements in villages and towns. Ensuring that not a single child, especially the female child, is deprived, will mean that these facilities must be provided free of charge by the state.
Ensuring excellent education will necessitate marked improvement in primary and secondary schools.
If these can be ensured, it must follow that for higher education – as in such fields as medicine, technology and law – all admissions and appointments must be on the basis of merit and merit alone. This is the only way by which we can restore standards in our colleges, research laboratories and universities.
| Setting up a Resilient System Capable of Dealing with Unexpected Crises|| |
COVID-19 is just the latest example of medical crises that have hit our people with disastrous results. The various preceding epidemics appear to have taught us little.
We have no systematic plan for dealing with such calamities.
Our official hierarchy is flawed. Depending, as it does, on government and its agencies, it can only be as efficient as are those working in them. Decades of political interference and unsound and defective appointments to high positions in our many august funding and monitoring agencies have ensured that decision-making is distorted and oft erroneous.
Since each agency considers itself an empire and there is little quality control or cost–benefit assessment of its function over decades, it is not surprising that their combined efficacy is poor. The fact that almost all agencies have no teeth and cannot enforce discipline further reduces their usefulness.
Taking the COVID19 epidemic as an example, we have had no respected, central, unified, authoritative and purely scientific group taking charge. Since we are dealing with a virus infection, we would expect the creation of an empowered group of our outstanding virologists and public health experts, drawn from such institutions as the All India Institute of Medical Sciences, New Delhi; Christian Medical College and Hospital, Vellore and National Institute of Mental Health and Neurological Sciences, Bengaluru. This group would direct research in India into appropriate and productive domains, monitor and analyse emerging findings in transparent meetings and provide recommendations for action by authorities and guidelines for the population. Monitoring by this group would enable appropriate changes as new facts emerge on this hitherto poorly understood disease. It would ensure that empirical suggestions and advice based on unscientific grounds were shown up for what they were and that the public was cautioned against them.
Instead, we have spokespersons from various governments, institutions, agencies and groups and retired heads of departments and institutions, who have been issuing guidelines and statements that are at times contradictory.
Our medical watchdogs – the medical councils – and the various associations and societies of medical worthies have been strangely silent on our national and regional management of this epidemic.
They appear content with blundering along.
| Conclusion|| |
Can we change the status quo?
Efforts of individuals and groups working in such areas as Anandwan, Jamkhed, Gadchiroli and Ganiyari have shown us that given the will and enthusiasm, it is possible to overcome obstacles.
We need a resurgence of the principles that stirred and stimulated such individuals as Baba Amte and his family, the Aroles, Abhay and Rani Bang and P. K. Sethi.
We need individuals cast in the mould that created Aneurin Bevan, characterised by cast-iron integrity and a raging passion and the creation of what Nelson Mandela termed sacred warriors.
It will take much persistent and continued effort, sacrifice and diligence.
We need to revive Gandhiji's concept of those in power being the trustees of the nation. If we succeed in instilling a fervent desire in each of us to be a Vaishnava jana, there is hope.
I have been greatly helped by an unpublished paper written by Dr. Sanjeev Jain, Professor of Psychiatry at National Institute of Mental Health and Neurological Sciences, Bengaluru. Whilst it deals principally with Dr. J. B. S. Haldane and the Bhore Committee report, it embodies many facts on our current medical situation and suggestions for correcting them.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| Suggested Reading|| |
Anonymous: Declaration of Alma-Ata International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978. https://www.who.int/publications/almaata_declaration_en.pdf. accessed on 10 September 2020.
Bhore Committee Report in Three Volumes. https://www.nhp.gov.in/bhore-committee-1946_pg. accessed on 25 August 2020.
Dabade Gopal: 40 years of Alma-Ata: steps India Can Take to Achieve 'health for all'. Business Standard 2 September 2018. Accessed at https://www.business-standard.com/article/current-affairs/40-years-of-alma-ata-steps-india-can -take-to-achieve-health-for-all-118090200095_1.html on 1 September 2020.
People's Health Movement: People's Charter for Health 2018 Accessed at: