Neyyar Dam Trail

Snaps of a mini trail in Neyyar Dam. Quite welcome greenery . . .

Medical Education in India . . . A clarion call for Family Medicine as Specialty

The scenario of public healthcare in quite a large part of the country is in shambles. This is no secret. There are powerful lobbies within the country that are bent upon seeing off the remnants of public healthcare in whatever state they are in now. Healthcare as of now has become a commodity which is much beyond the reach of an average Indian in most of the states of the country.

There are questions being asked about the propriety of healthcare being put in as a basic right of each of the citizens of the country. The result has been quite gruesome.

Basic health indices like Maternal Mortality Rate, Infant Mortality Rate etc. are so dismal in quite a many parts of the country that both the care-givers and the cared are well versed in sweeping adverse health events under the carpet. Latest reports say that we're in for real trouble with tuberculosis.

States like Kerala, Tamilnadu etc. have made major strides in healthcare whereas states earlier known as the BIMARU states, and presently designated as the Empowered Action Group states are a major blot for the healthcare prestige of the nation.

The question remains on how serious we are about this?

One aspect to look at is the healthcare manpower of states in general. I would like to start off with the availability of doctors in various regions of the nation. I do not have numbers from the respective State Medical Councils. However, there is readily available information about the number of seats for MBBS in the different states of the country.

Of course, I would have critics tell me that the presence of doctors alone is not enough to ensure that the nation is healthy. There are countries like Sri Lanka who depend more on nurses for primary care than doctors, thereby ensuring that healthcare indices are much better than even places like Kerala or Tamil Nadu.

Going back to availability of medical graduate seats in various states, I would like to draw your attention to the table below . .. …

Take a look at the below facts . . .

a. Kerala and Tamil Nadu which has got a combined population which approximately totals the population of Bihar has 70 medical colleges with a total of about 9000 MBBS seats whereas Bihar has a measly 13 medical colleges with a total of 1200 seats.

b. I thought of looking at Gujarat as we have NaMo, the present Chief Minister claiming all qualities to don the mantle of Prime Minister after the next parliamentary elections. With a population which is almost double that of Kerala, Gujarat does neither have the number of Medical Colleges nor the MBBS seats that Kerala has. Poor marks for that, Mr. Modi!

c. You may be wondering on how I arrived on the calculation of doctor per 100,000 population. I made the supposition that each medical graduate would serve the nation for at least 40 years after graduation. However, there is a problem here too. For India, the calculation says that there would be about 160 doctors per 100,000 population. However, on the ground, we have only 62 doctors per 100,000 population. For comparison, Cuba has 672 doctors per 100,000 population. I have not taken into account the major brain drain in the field of healthcare which continues in the country.

d. I’ve not taken also into account doctors who are graduating from other countries and coming back to India. Experience says that the numbers of such doctors are also more from the better off states rather than the EAG states. And of course, doctors who would have spent quite a lot for their studies abroad will never be much inclined to serve the rural areas. However, I’m sure that there is no point blaming them as our graduates too do not prefer serving Bharat and instead preferring the shining India. 

Now, I’m going to give another twist to this whole issue. Recently, there was a major statement from a leading healthcare professional about the need for more specialists in the country especially for the specialities of cardiology, diabetes etc.

Of course, with only measly group of medical graduates passing out each year in terms of requirement of the country, it becomes all the more tough to make them specialists in various fields of medicine. And the biggest question is whether we require specialists for each branch of medicine.

In one of my previous posts, I had explained quite in detail about the realities about availability of specialists in remote areas of the country, such as ours.

Here, I would like to look at how we would end faring if the situation remains status quo.

One major concern is poor obstetric care. Why don’t we look at the speciality of obstetrics?

Below is a very similar table to the one above. The only difference being that, we’re looking at the number of obstetricians that colleges in the same states churn out every year.

The number of obstetricians who pass out each year in Tamil Nadu is more than twice that of Kerala. There is no point in looking at numbers from the other states. Uttar Pradesh, which has almost 3 times the population of Gujarat has almost the same number of obstetricians passing out each year. The maximum overall conversion rate from graduates to obstetricians is a measly 4%. For comparison, almost all developed countries has more than 10 obstetricians per 100,000 population.

In a hospital setting where we have a sick baby, a mother for antenatal care, an elderly man for diabetic control, a mother in labour room who needs an emergency Cesarian section, we expect to have a Pediatrician, Obstetrician, Internal Medicine Specialist, and an Anesthetist.

I was trying to do some calculations.

Suppose one obstetrician can supervise approximately 200 deliveries in a month, which amounts to about 2400 deliveries in a year. In Jharkhand we have an approximate birth rate of 24 per 1000 population. Therefore, we would do well with one obstetrician for 100,000 population. Unfortunately, although this looks good when we calculate availability according to the number of post-graduate seats in obstetrics, it does not work well. For example, the region of Palamu, Garhwa and Latehar districts which has a total population of approximately 4 million has only about 10 obstetricians on paper. It should have had 40 obstetricians. I understand that practically, there are only 3-4 obstetricians in the region.

Now, according to rules, we need to have an anesthetist wherever there is an obstetrician. Below is a table showing status of anesthetists in the same states.

But, do remember that anaesthetists are not only required by obstetricians, they are needed to work alongside any of the different surgical specialities. So, the anaesthetists need to be much more than the number of obstetricians.

Now, if we apply the same rule to other conditions, we shall soon find out the enormous challenge that we have in our hands.

I’m sure that this is the case scenario for almost all specialities. All of us know quite well that the number of post-graduate training opportunities available to MBBS graduates is on the lower side. The National Board has tried to offset this shortcoming by arranging DipNB courses in private hospitals. There are challenges here which are beyond the scope of this article. 

To complicate issues, on the healthcare side, the burden of non-communicable diseases is on the increase. There are calls for more specialists in the areas of diabetes, cardiology, oncologists etc. However, do remember that we still grapple with basic healthcare issues such as maternal and child health care, infectious diseases such as malaria and tuberculosis. For completion sake below is a table which shows the number of Internal Medicine consultants and cardiologists who pass out from the same set of states.

Availability of clinical care in rural areas of the country is a major issue. Of course, there needs to be major inputs into infrastructure development of public health facilities in all tiers of clinical care. States such as Tamil Nadu and Kerala has already shown us the way in this realm.

If one closely looks into the Kerala model of healthcare, one can very easily find out that the availability of graduate doctors in grass-root public health facilities, namely the Primary Health Centre and Community Health Centres has been one of the key reasons for healthcare equity. The challenge is to replicate this model in this era of specialisation.

And in Kerala, I find the justification about equipping PHCs and CHCs adequately. Because till about 5-10 years back, the total medical graduate seats in Kerala was not more than 800 seats. And still with that number, Kerala was successful in bringing to quite a certain extent in bringing about healthcare equity.

In the present era, considering into fact the reality that post-graduation is the norm in the field of healthcare, we are in a quandary. In addition, there is a fall in standards of medical education all over the country. It is not uncommon to find MBBS graduates who do not understand anything about clinical medicine and finds it difficult to practice. In such a scenario, a post-graduate speciality for training in general practice is very much necessary.

And this is exactly where a Masters course in Family Medicine would be of benefit.

For uncomplicated cases of pregnancy, do we need an obstetrician around to supervise delivery? For a routine care of diabetes, can we afford to have diabetologists all around the country? Even, for an acute cardiac event, are we entertaining the possibility of only a cardiologist managing the case? Of course, for the rich and the powerful, affording a specialist would not be an issue. The question remains of the common Indian citizen.

And this is where exactly a Family Physician would fit in.

In a situation where we can equip our Primary Health Centres with couple of Family Physicians, the workload on our referral centres would come down quite a lot. And the cost of healthcare would come down to quite a large extent.

Would like to have feedbacks for this post . . . 

Of treasures on earth

It was quite encouraging to see a news item about the pope taking a stand for the poor and putting on record about the idolatry of money being responsible for the recession which has resulted in unemployment and increasing poverty. He also made efforts to reach out to the poor and the most marginal and priority of his pontificate.

Over the last 3 weeks, while I was in Kerala, one of the harsh realities that smash onto us the major influence that money has wielded in the Christian community of the state.

3 instances to just put across on the treasures we value. I know this can be harsh on some of my own very close friends and maybe you will tell me that there are instances worse than these.

-          I was told of a wedding reception in a church where the cost of each plate of food was 600 INR. That was the first time I heard of such a high cost per plate. Later when I discussed about this with a friend, I was told that he had heard about a wedding reception where per plate food was 1200 INR. And it seems that 600 INR per plate was not quite an an uncommon affair for a wedding reception.

-          One of the churches I frequented long back was doing an extensive revamping of its sound systems. The cost – a whopping 800,000 INR. I could not help but think that we could have brought a ventilator if we had that amount.

-          The worst of them all – I know of a church building which was made with a total cost of approximately 20 million INR. The issue was that the church was in a debt of 10 million INR after the construction was over.

I’ve heard quite a lot of statements from the pulpit about the opposition of the church towards extravagant spending. However, that was the maximum anybody has done about it.

Don’t you think that it is high time for us, especially believers of the Lordship of Jesus Christ in our lives to take a stand for simplicity and against extravagance?

I firmly believe that opulent living and spending within our country is a crime and very much against the ethos of the Christian faith.

Could I go one step ahead?

One of the serious issues in the Christian church is about the poor in churches not been heeded to nor given any sort of pastoral care. I repeatedly hear about pastors and clergy who are not interested to visit the poor and the not so rich in their pastorate/parish.

Could each of us take a pledge to make the poor and the marginalised in our communities and churches an active part of our fellowships? 

Boating at Veli

After our visit to Veli during our previous visit to Trivandrum, I was determined to take take the children on a boat ride the next time we visited provided there was no rain. 

We did it this time . . . Few snaps from the ride . . . 

The boat jetty . . .

The KTDC floating restaurant

The lake meets the sea . . . 

View from our home

The monsoon has been quite strong all over country. And in Kerala, it's been raining almost everyday. 

And the greenery which has enveloped the place cannot be described . . .

The view from the window of my bedroom in Othera today early morning . . .

God's Own Country

Snaps of a place I think is the one of the most beautiful in Kerala. Any guesses . . .

I'm sure that very few of you got this right. This is Neyyar Dam, which is about 20 miles from Trivandrum. You can very well see that these snaps were taken in 2006. 

Next week, I'm planning to once more go to this place. Shall definitely post the snaps .. .. ..

Malampuzha Dam . . . A Photo Blog

The Malampuzha Dam situated in Palakkad District, Kerala is a must visit in the life of anybody in Kerala. It is not uncommon to find schools having the place in it's schedule for a tour at least once in 3 years. 

The below snaps were taken almost 6 years back . . . 

The dam masonary

The hills and greenery on one side of the dam

Another view . . . .

View from the top of the dam . . . 

The view towards the mountains . . . 

The fountains . . . 

Another fountain . . . 

The gardens . . . as they start to get lit

Cement Umbrella . . .

A canopy for the weary tourist in Malampuzha, Palakkad District, Kerala . . . 

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Monsoons . . .

Monsoon . . . A word that is unique to the country. When I recollect the word being mentioned during my childhood, I used to think that it was slang for rain. It was after quite a long time, I realized what it meant.

Childhood memories remind me of the first day to school. In Kerala, usually school starts sometime during the first week of June. And I remember that most of the days, the first day of school was characterized by heavy rains . . . 

I distinctly remember one of the years during our stint at Kollam, Kerala. We used to travel by a cycle rikshaw to school. I was in the 1st or 2nd standard. There were about 6 of us, crammed together. It had started drizzling by the time we had made some progress towards school. We could see the dark clouds laden with all the water coming at us when our rikshaw puller decided to put plastic sheets improvised to shield us from getting wet . . . 

Our rikshaw driver also had a custom made conical shaped plastic sheet which he draped over his head. It was quite a sight. 

As expected, the rains lashed us as we crawled through the town towards our school. It was as if someone was pouring huge buckets of water on us. We had expected the rains to stop as soon as we reached school. On nearing school, it was a nightmare. The roads were all water-logged. 

And it being the first day of school - there was quite a large crowd. In addition to parents, there were proud grandparents, uncles, aunties etc who had come to see off their grandchildren, nephews, nieces etc to school. Our rikshaw driver realised that we would have to wade through the water. 

I looked down on my shoes with brand new white socks. Then at the brackish water from the overflowing drains . . . It was revolting. Then our rikshaw-driver made the most amazing offer. He offered to carry each one of us to school. I don't remember who he carried first. 

I felt very awkward. Although only being in the 2nd standard, I was not exactly of that built that anybody will want to lift me up. Being on the heavier side and being a bit self conscious, I did not my friends to see me being carried to school through the flooded road. 

I made up my mind. I was going to remove my shoes and socks and walk through the water myself. As I prepared, our friend was back for his next trip - but confidently told us that he has found a short cut to take us nearer to the school gate. I was relieved. . . 

Over the years, I've realized what monsoons mean for the country. If reports are true, 60% of cultivable land in the country depend on the monsoons exclusively and 60% of the country's population depend on the farm sector for a livelihood, although it only accounts for only 15% of the Gross Domestic Product of the country. 

Years later, as I sit in the hot environs of Jharkhand, I wish I could be witness to the magic of the monsoon as it hits Kerala. The idle evenings after school spent watching the rains fall and fall, the nights when the pitter patter of the rains seem like a symphony gone awry, the days when we had to run in the rain after we had forgotten to take our umbrellas, walking through the slush with the unexpected puddle hidden somewhere, vehicles dashing through the road splashing mud and water on us, the Sunday morning walk to church . . . I miss all of those . . . 

Last year was a blessing for us. We had enough rains. Our pond had got filled up. We had put fish in it. . . and harvested about 250 kilograms of common carp, grass carp, silver carp, rohu etc . . .

Today, I heard that the rains have hit the coast of Kerala. . . We pray that we would receive a sliver of it as it progresses towards the North. . . Palamu district is known to be a rain shadow region. But, we pray that 2012 monsoon would remember our region. We dream to see a filled up pond. . . and to grow fish for the next year . . . we dream to see greenery around us, people working hard on their fields, people not needing to go away from home for work . . . and of course temperatures to come down . . . 

It was only recent that I read about theories of how successive years of monsoon failures may have wiped out the Harappan civilisation . . . Amazing that we are the mercy of the winds bringing moisture from the southeast seas to fuel our supposedly trillion dollar economy . . . We can only pray and wish that we would have a bountiful monsoon 2012 . . .

ALL THE WAY FROM HOME (God's Own Country) . . .

BK, a 20 year old young man was brought by his brothers to the emergency at NJH sometime late afternoon. I happened to see him as soon as he came in. He looked quite sick and had yellowish eyes and was putting out dark colored and blood tinged urine.

BK’s brother told me that BK has just reached his home in a village nearby in Manika block. He works in somewhere in South India and has developed fever in the train. It was very high grade fever associated with chills and rigor. BK had blood shot eyes and it was obvious that he either had hepatitis or something else.

But, the diagnosis was quite easy once I found out where he worked. BK was a bit stuporous but he was conscious enough to answer my questions. To my astonishment, BK worked in Kerala. And where in Kerala? He worked in a pineapple estate.

As he told pineapple – I knew the diagnosis and my heart could not wait to ask the next couple of questions and it was obvious that most probably he had leptospirosis.

BK had been working in Kerala for the last 2 years somewhere near Perumbavur, Kerala in a pineapple plantation. It is very commonly known that workers in pineapple plantations are very much susceptible to leptospirosis. It basically occurs because of the pricks they receive from the pineapple thorns. And when they touch contaminated water, they get the disease.

Then I found out that BK knew Malayalam. You should have seen his face, when I asked the next few questions in Malayalam. Poor guy, he got the shock of his life to find a Keralite doctor working near his village. So much so that he was soon out of his stuporous state – though looking sick.

But more surprise waited for him in the Acute Care Unit. He must have got really psyched out when he found out that the nurse who attended to him as he reached the Acute Care Unit was also from Kerala.

His blood investigations were also very much suggestive of leptospirosis. He was lucky that his renal parameters were just turning bad when he came in. He has made an amazing recovery with high dose Penicilline.

Today evening, as I took rounds, BK told me that the previous day he thought he was dreaming when he found the doctor and the nurse asking him questions in Malayalam. He believes that a miracle has brought him here where we could make the correct diagnosis.