How do you trigger a never-ending debate on Twitter about health? You have two options. Either talk about a bridge course from Ayurveda into modern medicine. Or talk about compulsory rural service.
Why, though? The superficial reason is that Twitter is a stupid medium where there is not enough space to make a nuanced argument. The deeper reason is that it is not clear whose responsibility "health" is. And that's because there are two ways of defining what "health" is.
There are folks who take health to mean absence of diseases. Even when the community medicine department in medical schools keeps talking about WHO definition of health, many medical graduates focus on "diseases" because the rest of the medical school talks only about diseases. This percolates to the rest of the society and in the overall society there is a clear notion that health is the absence of diseases and that healthcare is access to curative services.
The impact of this definition is most strikingly visible in what people coming out of medical schools tend to do with their lives.
They seek specialties and super specialties (like interventional radiology, dermatology, and cardiology). They do not have a problem in spending one, two, or three years in trying to get post-graduation seats. They seek work in the largest hospitals in the largest cities. They make their life about "diseases" and restrict their role to providers of disease-curative services.
But this definition is not just restricted to doctors.
- Faculties in medical schools continue to teach students that health is about "diseases". (Even in some community medicine departments).
- Government of India spends a significant share of health budget on setting up/upgrading hospitals and on reimbursing curative services through elaborate insurance schemes.
- When there is a pandemic, technologists rise up and try to "help" with their mathematical models. But they don't think they have anything to do with health during non-pandemic times.
- People think about health only during bouts of illnesses. They pay for healthcare only in the context of curative services. (Or insurance premiums for schemes that apply only to curative services).
- There is no talk about health during election campaigns.
There is a wider, (arguably more "real") definition of health - as a "state of complete physical, mental and social well-being". This is often forgotten. As per this definition, we have country full of unhealthy people. And people who stick to this definition make the case that health has as much to do with the society and its politics as it has to do with hospitals.
They argue that education, opportunity (to make a living), dignity, equality, rights against exploitation, justice, access to technology, and so many other factors go into deciding whether individuals are healthy.
When it comes to doctors (and other medical professionals), they have two ways to spend their lives in this society.
- Follow the narrow definition of health where all that matters to them is the survival of their "patients" - those who come to the hospitals.
- Follow the broader definition of health where they are leaders and change makers and politicians and advocates.
Unfortunately, in the never-ending cycle of disease management and education to manage diseases, most of our medical professionals (doctors, nurses, etc) are not trained to take on the broader definition of health as their "job". Which leaves them restricted to following the former kind of life.
The broader definition of health is then left for a very small set of people to work on. They are variously known as "public health professionals", "family physicians", "primary care practitioners", "community health specialists", etc.
The task for this small group of people, on the other hand, is humongous. While delivering curative services require to match demand with enough supply of resources (human and non-human), working on the larger definition of health often needs a whole different approach. For, the problems in (social (?)) determinants of health like gender, class, education, economic condition, and so on often require action beyond individuals and institutions. Some of these work span generations. And there is no linear progress. Sometimes societies regress to worse conditions too.
Now, here is the problem. This bigger task should not be and cannot be done by "medical" professionals alone. It requires collaborative action from communities, lawyers, politicians, engineers, economists, artists, historians, every person imaginable. Because that work is not related to "medicine" alone.
Now, let us look at the controversial topics that we started this post with.
In both bridge courses and compulsory rural service what the governments seem to be trying to do is to increase the number of "qualified" doctors (and hopefully other medical professionals) in rural areas. We can assume that their assumption is that if there are enough trained curative service providers, there will be some respite.
And they are probably not a 100% wrong in making that assumption. If a person with wisdom and training goes to a place that can benefit from that wisdom and training, that place will benefit at least a bit. (Taru Jindal's story is an example).
But there are some important counter-arguments
- The nature of these policies are sometimes objectionable. "Mandatory" rural service is as controversial as mandatory military conscription. Bridge courses may often be seen as unscientific or unfair.
- The training in medical schools (especially when they get more "specialized") need not be tuned to the context and needs of rural communities. Even if medical professionals are trying to deliver only curative services, they can be quite disoriented when they find that they don't have the investigations and interventions they need at arm's length.
- To stress on the point of training, there probably is very little of leadership training in medical schools and often in communities where the health system is next to nil leadership is a critical element in being able to set up systems.
- The kind of leadership challenges one faces in rural communities could be different, and the solutions might often require larger systemic changes (refer the broader definition of health).
It is counter-productive to train a generation of medical professionals in delivering curative services in cities and then expect them to perform in a broader, entirely different, and disproportionately more challenging role as health care leaders in rural areas.
You can send them to well functioning hospitals with all facilities in rural areas and they probably will find their groove. The irony is when you are sending them to rural areas to build such hospitals and/or systems for health without giving them any training in that.
And it is not all medical school training that I'm talking about. It is also the societal training. We as a society are training many professionals (doctors, engineers, included) with a very narrow definition of purpose and meaning ascribed to their profession. If you are a doctor - the meaning of your life is to treat the sick. If you are an engineer - the meaning of your life is to plan and build things. And so on. When have we, as a society, encouraged people to ask larger questions. Like "Why are people falling sick?", "Why does this thing have to be built?", "What is my role in perpetuating the system the way it is?", "How is it possible that there are widespread inequities in the world while there are enough resources for all humans to have a dignified life?", "How are our decisions and actions endangering the survival of this planet?", "What is the relation between care for others and democracy?"
The questions that matter often have solutions that require collective action. And that often includes many kinds of individuals (no matter what their "job" or "background" is) to take action. Sometimes that includes you. Do you consider that as your responsibility? If you do not, then you are part of the problem.
