Lucky us . . .

Today morning, I read an article about cost of medical graduate studies in the United States. 

That was the time, I thought about calculating how much I had spent for my studies in Medical College, Trivandrum. I was a day-scholar. The total costs did not cross 40,000 INR (approximately 1000 USD according to exchange rates at that time). 

That was 1995-2001. 

I thought about looking at latest costs. My colleague, Dr. Titus had done his MBBS during 2005-11. The total costs just crossed 100,000 INR (approximately 2000 USD according to exchange rates then).

Well, I need not voice it out. 

One can only think about the umpteen number of MBBS graduates from third world countries such as India who have enriched healthcare in countries such as the US. And of course, the umpteen come from the sparse numbers who pass out of Medical Colleges in such countries. 

The sad question is - 'At whose expense?' 

And considering the article, the graduates from the developing countries have a head start to the American graduates who are deep in debt when they start their career in medicine. 

I could be prejudiced by the article I mentioned. Would value enlightenment if I'm wrong. 

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 . . . 

Sad stories . . .

It has been a very unusual Wednesday so far .. .. .. 3 cases within 6 hours which tells you a whole lot about the condition of healthcare in most parts of our great country . . . 

I had just walked into office when one of the local villagers brought a very sick looking girl into casualty. The 9 year old girl had been sick for the last 15 days with fever. The local village quack was managing her . . . with herbs and roots. 

Yesterday, she became unconscious. And the family did not know what to do till one of the neighbours told them to rush the girl to us. 

She was all yellowed up. And only a sigh of her breathing told us that she was alive. GCS of 3/15. Her serum bilirubin was a whopping 28 mg%. We are still not sure of what we are dealing with. 

So sick and they did not even think it worthwhile to show her to a proper doctor. 

Well, you'll realise what use is it many a time even if you show to a regular doctor. 

Just couple of hours after the above patient came in, a young lady was wheeled into emergency. She was dead. It did not need much of a history for Dr Johnson to make a diagnosis. 

Mother of a little girl who just turned two yesterday, she experienced severe abdominal pain at 3 AM today early morning. She had missed her periods by 2 months. 

She had visited 4 very good doctors over the 6 hour period she had spend in our nearby town. All big, big names in clinical practice. Anafortan . . . fortwin-phenergan . . . these were the drugs she recieved. 

Nobody could think about a ruptured ectopic. We took permission for a undocumented ultrasound and the results were there. It was a ruptured ectopic. 

It was unthinkable .. .. .. A young mother who celebrated her daughter's birthday less than 24 hours back lay dead in front of us. 

The last case was another young lady my colleague saw in outpatient almost the same time. A very obvious case of enteric fever . . . She has received about 20 different types of medicines from 2 quacks and 1 qualified doctor. All of them has nothing to do with enteric fever. 

One cannot blame a patient who goes to a quack if he fails to get a clear communication and evidence based treatment from a doctor who has a recognised medical qualification . . . 

Time we look seriously into medical training in India . . . 

Funding . . . The Paradoxes in Indian Healthcare - Part 2

The other day during a meeting, someone commented on how easy and freely available is HIV testing in almost all government facilities compared to other investigations such as hemoglobin, urine albumin etc. Someone suggested that even there are places where HIV testing is available, but a sphygmomanometer to measure blood pressure is not available. 

I'm afraid that this situation is actually true. 

There is quite a lot of funding available for HIV. But, no money for Reproductive and Child Health Care. So, no sphygmomanometers or instruments to measure hemoglobin or urine albumin. Well, I would not need to do explanations on the importance of doing a hemoglobin for a pregnant lady as part of her antenatal care. Or a routine check up of blood pressure. 

I'm not touting for HIV testing to be stopped . . . it is a lifeline for babies who are born to mothers who could be diagnosed to be HIV positive. But, we need to rule out anemia for all our women who become pregnant . . . for anemia is supposed to be the commonest indirect cause of maternal mortality in the world. 

Talking about maternal mortality . . . it irritates me when the Polio Surveillance officer calls me every Monday to check out if there has been any case of Acute Flaccid Paralysis in the hospital over the week. I'm not irritated because I don't like this guy . . . he's in fact a good friend. I'm irritated because there are young mothers dying while giving birth. We fill up the Institutional Death Reviews and send them . . . On October 18th, it will be one year since we've started the reviews. Till today, I've not been called for any meeting related to any of the deaths. 

Leave alone maternal deaths, I've had men, women and children coming with symptoms suggestive of viral hemorrhagic disease most probably dengue . . . nobody turned up until someone accidently put it in the papers. Still the response has been quite muted. There were 3 proved cases of cholera in the hospital. I informed the authorities responsible. No response. 

It does not need any brains to explain that nobody is interested in maternal deaths, tuberculosis, malaria or cholera as there is hardly any money in it. There is money in HIV, Polio . . . even cancer. And now, Non-communicable diseases. Because that's what the West is quite concerned of. HIV, polio . . . because they are quite concerned that we will transmit the diseases to them. 

Non-communicable diseases - - - so that they can get back all the expenditure spent on research of drugs which have been proved to be either useless or has side-effects. Recently, I had a mail from one of my elderly friends (not a doctor) who told me how he was 'detoxified' from all the medicines he and his wife had been prescribed by his cardiologist et al in India, after he went to the US to be with his son. He was put on a regular regime of exercises and dieting. He is doing good with no problems . .. ... 

My previous post had been on the pharmaceutical industry. Even for the pharmaceutical industry, there is nothing much in store from maternal or child health and infectious diseases such as malaria or cholera. 

There is only one solution for this issue. Our friends in the Health Ministry needs to realise the pressing healthcare issues of the country and ensure that funds and personnel are available for research on those issues. We have enough research to show that the metabolic functioning varies in cultures and races. Following research, we need to have systems put in place such that the research can be converted into action. Only then, can the real needs of healthcare in India be addressed . . . 

Depending on funds from any organisation abroad would only ensure that public healthcare issues of those regions would only be addressed and we would remain with healthcare issues such as Maternal and Child Health, Tuberculosis, Malaria etc which we have been continuing to grapple with since ages. 

Coming to funding . . . there are more issues. Like the issue of adequate infrastructure not available for Primary Health Centres and other public healthcare institutions to start. And worse than that is the all out dependence on Private Medical Colleges to help us with staffing our Health Centres with doctors . . . Well, that is fodder for another post . . .

Malnutrition . . . A perspective . . .

Of late, there has been quite a lot of news items including reports on the honorable Prime Minister commenting on malnutrition among Indian children.

I know that all of us can give umpteen reasons for the predicament of our children.

In the light of couple of incidents that happened today in the hospital, I wonder whether 'the perspective' which I want to raise is another very significant determinant of the poor state of healthcare  in our country.

I was on my rounds today morning, where I came across RA who had delivered by Cesarian Section couple of days back. RA told me that she was not secreting enough breastmilk. I asked RA's mother nearby on how often the baby is passing urine. RA's mother told me that she has lost count. In fact, she was cleaning up the baby when we reached RA's bedside, and she looked quite exhausted, which was quite explainable...

Then I suggested to RA that if the baby was passing urine, then the baby must be getting something to feed. RA replied that when she squeezes her breasts, there is not much milk coming. I told her not to worry and to only ensure that the baby is put to the breast at least once in hour hours and then if she demands.

RA did not look very happy . . .Then, to my horror, as I left the ward, the accompanying staff suggested that I write a prescription for a popular breast milk substitute. So much for promoting breastfeeding . . .

Unfortunately, this is not the first time I had a incident similar to this . . . and I had taken the pains to teach my colleagues on the importance of ensuring breastfeeding . . .

4 hours later, I had a patient in OPD . . . Unfortunately, I did not recognize her. She was RK, who had delivered exactly 35 days back at NJH. The complaint was that her baby was very lethargic . . . RK served as a Auxiliary Nurse and Midwife (ANM) in one of the Primary Health Centers in the district . . .

On a cursory glance, it was obvious that RK's month old baby looked small. . . Her weight was a measly 2.8 kg . . . And her birth weight was 2.5 kg . . . . And her weight today was measured with quite a good amount of clothing on as it was quite cold . . .

RK was a trained ANM from one of the reputed institutions of the state and she held quite a senior position within the public healthcare system of the region . . . 

And she had not recognized that her baby was not gaining enough weight . . . RK was responsible for the well being of mothers and children within quite a large area . . . I can very well imagine how much knowledge she has to impart to her target community . . . 

I had a incident which echoed the same sentiment couple of months back. . .  Which was a bit more sad as the SD, the patient died of complications . . .

What I'm concerned about is the knowledge element of quite a lot of staff in the healthcare services. . .  It is very well known that many of them get into the job by unscrupulous means . . . But, at whose expense??? 

Of course, there are other factors which ultimately contribute to malnutrition . . . But, incidents such as these show that many of our  babies start their lives with a severe disadvantage on account of poor knowledge imparted by healthcare staff who themselves are not very sure of basics . . .

It is high time that, concerned authorities in medical education seriously look at principles which ensure that the right concepts are passed onto students of all healthcare disciplines and market dynamics such as a powerful lobby for breastfeed substitues do not rule the roost and force us into unethical decisions  and practices . . .