India’s “rural doctor” proposal stirs criticism

India is no exception to the adage that the thoroughly trained modern physician isn’t generally inclined to set up a shingle in a remote, rural region of a nation. But in a bid to resolve its severe shortage of medical professionals willing to toil in rural areas, the government has proposed to overcome that truism by creating a new category of physician called the “rural doctor,” whose training won’t be as intensive and thorough but who, theoretically, will be more willing to practice far from the beaten path.

Critics, though, are lambasting the notion of doctors providing health care despite having had two years less training than those who’ve spent 5.5 years in medical school to obtain a Bachelor of Medicine and Bachelor of Surgery degree.

Such a “sharply truncated” medical education will only produce “registered quacks,” says Dr. Kunal Saha, president of the People for Better Treatment, a nongovernmental organization working to eradicate medical negligence and promote corruption-free health care in India. “Don’t we already have a lot of quacks in rural India?”

With a population of more than 1.2 billion people, India has long suffered from a scarcity of doctors, nurses, health workers and public health professionals. “Against a desirable rate of 1 doctor per 1000 population, we have 1 doctor per 2000 people. Against a norm of 3 nurses per doctor, we have 3 nurses for every 2 doctors,” Prime Minister Manmohan Singh said a recent address (http://pib.nic.in/newsite/erelease.aspx?relid=85099). “This shortage is acute in our rural areas and in particular, in the northern, central and eastern regions of the country.”

The government’s solution?

A 3.5-year course in medicine that results in bestowal of a “Bachelor of Rural Health Care” that entitles its holder to practise in a village (http://pib.nic.in/newsite/erelease.aspx?relid=82518).

But Saha argues that’s a violation of a constitutional right that states “no person shall be deprived of his life or personal liberty except according to procedure established by law.”

For many residents of India, it is indeed a long way to Mumbai, which has prompted the government to create a “Bachelor of Rural Health Care” program in hopes of resolving acute physician shortages in the northern, central and eastern regions of the country.

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“Are the lives of rural Indians less valuable so that they may allow to be treated by half-baked registered quacks?” Saha asks.

The proposal is equally unpopular with the Indian Medical Association (IMA), which was so outraged by the notion that it called for a one-day nationwide strike on the issue earlier this year. While conceding that many physicians don’t want to work in villages, the IMA says the problem of poor health care in rural areas extends well beyond a shortfall in health human resources to include such factors as poor sanitation and inadequate access to clean drinking water.

Saha finds that gesture of protest a step beyond the pale. “While the association has legitimate claims against the government’s mindless implementation of health care laws and acts … to protest against the government by holding the defenseless patients at ransom is vividly wrong — morally, ethically and legally,” he says.

Within that context, Saha’s group filed public interest litigation in the Supreme Court of India charging that the strike was a violation of the Medical Council of India regulations and a betrayal of the Hippocratic Oath. It was a bit of grandstanding, to be sure, given that his organization was seeking an injunction to a one-day strike that was practically over, and all but impossible to enforce, even had it been granted. It was also somewhat moot as, in most states, doctors responded tepidly to the IMA’s call for a strike and opted instead to wear black badges in support of the call or to participate in rallies or meetings late in the day.

Others, meanwhile, question the motivations behind opposition to the new category of physicians and argue that the shortage in rural areas is such that creative solutions have become vital.

If there is no “radical change in the development paradigm of the country, and rural areas continue to lag behind the urban areas, doctors are not going to go to villages, period,” says Dr. Yogesh Jain, a member of the Medical Council of India committee that is crafting the curriculum for the so-called rural doctors programs. “This deficit in terms of rural health care has to be filled up, and this three-and-a-half-year course offers an opportunity. Social appropriateness would be ensured by picking up students from the same district where they get trained and then posted.”

Jain coolly notes that physicians have been remarkably silent about inferior care in rural villages in the past. Where, he asks, has “this equity concern been lurking when one talks about provision of determinants of health for rural and tribal people, such as safe water, well-equipped hospitals as opposed to poorly functioning health centres, all-weather roads and public transport on them, or ability to draw loans on non-usurious rates for common emergency illnesses? Suddenly when higher education and employment comes up, then we rally against any sort of positive discrimination? Why? Someone should speak up for positive reaffirmation for rural health care needs. Support for a new invigorated medical curriculum is one such technical affirmation.”

Others note that current medical curriculum in Indian medical schools has done little to promote rural practice.

“The existing medical education does not prepare the medical graduates to work for the community,” says Dr. Raman Kumar, president of the Academy of Family Physicians, which is working with several other bodies to develop a consensus statement on needed medical education reforms.

The time may have come for India to examine other models of providing care in rural areas, such as that of Brazil, where teams are made responsible for a given number of families in a well-defined geographic area, Raman says. In such a system, he adds, “medical graduates are prepared to work in the primary care setting in rural, urban as well as remote locations.”

Proponents acknowledge that there’s no guarantee that newly minted “rural doctors” won’t eventually pack their bags for more lucrative practices in urban centres. But Jains hopes that “proper selection, system support and appropriate monitoring can ensure that they continue in the rural areas from where they emerge.”