Friday, October 1, 2010

Diluting Medical Care

In July 2010 the Madras High Court, in a landmark judgment, ruled that doctors qualified in Ayurveda, Siddha and Unani systems of medicine can practice ‘modern scientific medicine’ along with their respective systems. This Judgment was further buttressed by a Government Order (GO) issued by the Department of Health, Government of Tamilnadu, permitting practitioners of traditional systems of medicine to prescribe allopathic drugs and perform a range of surgical procedures including orthopedics, gynaecology, ENT, Ophthalmology etc. To understand the grave dangers posed by this unfortunate decision, one must understand the evolution of traditional and ‘modern’ medicine.

Conventional medicine that is practiced around the world is often referred to as modern medicine in India. About two hundred years ago western medicine was poorly developed and many of the practices like bloodletting caused more harm than good. It was in this setting that Samuel Hahnemann introduced the philosophy of Homeopathy in 1796 . Homeopathy became popular not because it was highly effective but because it was perceived as not being as dangerous as the conventional medical system of the time. In fact it was Samuel Hahnemann who referred to ‘the other treatment’ as Allopathy.

It was only in the last two hundred years with the discovery of microbes, antibiotics, anaesthesia, immunization, modern pharmacology and other aspects of medicine that conventional medical care in the West overtook the traditional practices all over the world. Unfortunately many traditional systems in India and China did not evolve with the times and remained rooted in ancient practices. Today Ayurveda, Siddha and Unani do have limited patronage in India. Their adherents are usually those who are wary of modern systems and perceive them as being unnatural and therefore dangerous. In fact these traditional medical systems have capitalized on the very same sentiments to promote themselves as an alternate system of medicine. For others, traditional systems carry a heritage charm of being ancient and therefore exotic - in fact, esoteric.

Unlike traditional systems that have strong cultural and religious overtones, popular modern medicine has freely rendered itself to change and criticism. Modern systems evolved because they are not steeped in ancient traditions that have a way of being sacrosanct and rigid.

It is therefore surprising that these traditional systems are now asking to obtain privileges for prescribing the very same drugs that were denounced by them as being foreign, dangerous and unsuitable to our heritage. The foundation of Ayurveda, Unani and Siddha systems are alien to conventional medicine. For example, the concept of health and disease is based on the balance of the three humors namely Vatha, Piththa and Kapa in Ayurveda and Siddha. While these concepts may have merit for those who wish to follow them, they are meaningless to the practitioners of modern conventional medicine. A medical graduate in Ayurveda or Unani, tutored in these tenets will not be capable of practicing a science that has a totally different outlook to disease and treatment.

The judicial as well as executive decisions to allow traditional practitioners the privilege of practicing conventional - Allopathic - medicine is obviously based on the interpretations of the word ‘modern.’ The argument that traditional medicine is ‘modern’ is based on the specious argument that the syllabi of degrees such as BAMS and BSMS include ‘modern’ medical subjects like anatomy, physiology and pathology. Modernity in medical terms does not mean the knowledge of subjects alone. It refers to the application of modern methods in diagnosis and treatment based on well documented concepts. Drugs used in modern medicine and the rationale for their use is certainly in conflict with traditional medical systems. Systems like Siddha, Ayurveda and Unani that do not recognize microorganisms as the cause for infections cannot prescribe antibiotics. The defining aspect of modernity in conventional healthcare is evidence-based medicine (EBM). All drugs in modern medicine go through a rigorous process from drug discovery to phase trials to marketing. Even advances in surgery are based on recent developments in infection control, anaesthesia and operating devices that have been developed on the basis of principles that are alien to traditional medicine.

In this context the decision of the Tamil Nadu state government to allow traditional medical graduates to practice modern medicine, even while they adhere to different concepts about basic physiology and pathology, is a dangerous tryst with the destiny of healthcare in India. If the adherents of traditional medicine feel the necessity to practice modern medicine and prescribe drugs that are unfamiliar to their system, they are free to do so if they obtain a regular medical degree like the MBBS. Alternate medicine degrees like BAMS and BSMS cannot be used as a shortcut to practice modern medicine. One cannot have the cake and eat it too!!

Sunday, January 3, 2010

Lesser Doctors for Lesser Indians!!?

The Times of India on 30 th December 2009 reported an absurd proposal by the health ministry. Dr Meenakshi Gautham, a concerned health activist, filed a PIL in the Delhi High Court seeking to ameliorate the pathetic health condition in rural areas. I agree that it was something that should have been filed decades ago and then not just for the rural, but also for the urban poor. The Health Ministry and the MCI, on the direction of the High Court went into a huddle, in fact many high power huddles and then naively concluded that the magical solution for the rural folk will be to mobilize a new set of ‘doctors’ who are less trained (3 ½ years) as against the standard training of 5 ½ years for a medical graduate. This is not only discriminatory against the rural poor but a retrograde step that will create two tiers of doctors with two practice jurisdictions. The new set of BRMS graduates ( Bachelor of Rural Medicine and Surgery) will of course be expected to practice within the jurisdiction of villages while the others will stride the polished corridors of swanky city hospitals. This is an insult to the already deprived villagers who will now have the official classification of lesser Indians who deserve lesser trained physicians.

I must first pre-empt the usual argument of ‘something is better than nothing’ for these poor rural people and the repeated plaint about doctors refusing to serve in rural areas. The answer to this serious problem is not the creation of a lesser cadre for the lesser privileged but in addressing the fundamental problems in health management and manpower distribution. Most of us think that more doctors is a prescription for better health. Health, particularly at the grass root levels are achieved by education, awareness, prevention and health surveillance. It is no secret that the average doctor (rural or urban) would not be excited about pursuing these less glamorous aspects of health care.

I randomly chose a country in Southeast Asia and compared it with India based on available WHO statistics. Thailand is a much smaller country than India but has an economy that is somewhat similar. Thailand has a lesser physician density (3 per 10,000 pop) when compared to India which has (6 per 10,000) population. However every one of Thailand’s health indices is better. The life expectancy at birth is 62 years for an Indian whereas it is more than 70 for a Thai. About 79 out of 1000 live births are expected to die in India whereas the death rate in the same category is only 8 per thousand live births. Obviously, more doctors did not help the cause of public health in India. The key is commitment to health. This can be seen by the fact that the per capita expenditure on health is about three times higher in Thailand than it is India (Intl $ 109 in India and Intl $346 in Thailand). The density of nursing personnel in Thailand is twice as much as the nursing personnel density in India (28 and 13 for every 10,000 population respectively). Public spending on health in India at 0.9% of GDP is way below the public health spending in Thailand. In short, the health of a nation is not defined by the number of doctors but by the commitment of its Government. Nurses, Para -medics, health workers and maternity care givers are a greater need than poorly trained doctors. Doctors, even if they are called ‘Rural’ Doctors, are bound to chase the more glamorous aspects of health care. Nothing can stop these ‘rural physicians’ from slowly encroaching into the more financially rewarding urban and semi urban regions of the country. No regulatory body can practically restrict their activities to the ill defined concept of ‘rural’. Even legally, the courts will strike down as unreasonable restriction if a ‘qualified doctor’ is told to treat only people in a certain region (rural). It will be an infringement of the fundamental right to freedom of profession, occupation, trade or business under Art 19 (g) of the constitution. If a person can treat a rural person (as a bachelor of rural medicine and surgery) there is no way that he can be prevented from treating an urban person who has the same human features in anatomy and physiology. What is sauce for the goose is sauce for the gander !!!

The Government should focus its welfare intentions on creating incentives for doctors who are willing to serve the rural population. Creating another category of doctors and imposing unreasonable restrictions on their right to work can only be seen as an immature and poorly thought out strategy that has no respect for the sensitivities of the rural poor in addition to being hare brained and impractical.

George Paul