May 16, 2009

The case for a well-paid village doctor

Wouldn’t it stand to reason that the jobs that were the least satisfying ought to be paid the most? Of course, by that logic, a street sweeper ought to be paid more than a CEO. By that same logic, a rural medical posting ought to get more than the measly Rs10,000 that it commands. Double their wages, I say

My maid’s son gets epileptic fits. His name is Gerald and he is a young handsome boy of 16. Every now and then, sometimes three to four times a day, he gets these fits and simply falls down on the road, unable to move. People in the neighbourhood carry him home. Many days, my maid Teresa doesn’t send him to school because she is worried about the fits. Teresa is young, slim and cheerful, except when she talks about her son. Then, her pretty eyes get teary. Like most poor people, she is able to set aside her troubles and smile. She giggles as she works and has the capacity, if not the circumstances, for joy.

Doctors tell me that epilepsy is curable. With the right medication, it is possible to remain symptom-free, they say. My sister-in-law, a paediatrician practising in Florida, examined the boy and asked Teresa why she had kept Gerald in this condition for 10 years.

Teresa’s answer was plaintive: Where do we go for medical advice that we can trust? They had taken their child to every type of hospital within their reach. The Chinmaya Mission hospital, free government hospitals, the local Ayurvedic doctor, and even her village equivalent of a shaman. Now the boy was on homoeopathic medicines that they got from a doctor in Chennai.

My view of my maid’s condition boils down to a single word—and I am hardly saying anything original here—access. This access, or the “on-ramp” as my husband calls it, isn’t simple. If it were, my maid would have solved her son’s epilepsy problem. It isn’t simply a question of setting up 23,236 primary health centres (PHCs) across rural India, although that is necessary. My cousin works in one and the number of patients he treats every day would give a US healthcare company determined to squeeze the maximum out of its doctors pause. Like the residents of “Hotel California”, my cousin “can never leave”—not to visit his daughters, attend family weddings or even take care of his own health. His clinic is next door to his house and his “compounder” dispenses an array of green, red and white pills. The patients come from villages all around and wait for hours to see him for 5 minutes. The diseases he treats, however, are his old friends, brought on by poor sanitation and nutrition; lack of health education and safe drinking water. Simple things. Easily solvable. You’d think so, wouldn’t you? Not in the least, according to my cousin.

I come from a family of doctors and here is what I know about physicians. They take pleasure in healing. Their calling is to cure people, rid them of illnesses, dispense medication, treat complications. Managers, they are not. And Indian healthcare, in my humble opinion, needs managers more than it does doctors. Simply posting a doctor in Kalakkad village isn’t enough. Just as Lincoln Center has a manager and the conductor sharing the top slot, doctors and healthcare administrators ought to be deployed in tandem, maybe as husband and wife. The doctor dispenses pills; the administrator executes plans.

The healthcare administrator’s job, I would argue, is more important than the doctor’s. Except, in most villages, such a job doesn’t exist. The PHCs are manned by doctors and the panchayat leader squeezes in the sanitation and nutrition work amid her other duties. The ASHAs (accredited social health activists) do a decent job and are one of the most innovative schemes that the Indian government has come up with. But they are stretched. Just as the government recruited local women into becoming ASHAs, they can perhaps climb the ladder to becoming rural health supervisors. This supervisor’s job would be part PR, part brute-force execution and part infrastructure. She needs to convince the people who live on the banks of the Krishna that streaming their wastewater into the river will cause water-borne diseases downstream. She needs to cajole and coerce the village panchayat into installing toilets rather than having people defecate under the great blue yonder.

Part of the problem is that doctors, let alone administrators, don’t want rural postings. In late February, then Union health minister Anbumani Ramadoss announced that he was going to make rural postings compulsory even though, as many Indian medical blogs noted, they have “failed miserably” in the past. One medical education blog written by a Dr Anshu said that after being trained in medical colleges with sophisticated equipment and colleagues, doctors found the “learned helplessness” of rural postings frustrating.

This is one instance where I believe throwing money at the problem will help. Rural postings can only become attractive when they afford job satisfaction. Private charitable hospitals are doing a great job with this. Teresa is now taking her son to the Sathya Sai Baba hospital in Whitefield, Bangalore. We got her son an appointment via email and the neurologist is treating Gerald without taking a penny. The Mata Amritanandamayi Hospital has a waiting list of doctors wanting to serve, I am told. I am not a follower of “Amma”, or Sathya Sai Baba for that matter, but I would urge them to set up their institutions in remote rural spaces. The global manpower and funds they can draw will ensure a facility that will serve as a draw for not just patients but doctors and therefore, a thriving medical community that gives job satisfaction in rural postings.

Wouldn’t it stand to reason that the jobs that were the least satisfying ought to be paid the most? Of course, by that logic, a street sweeper ought to be paid more than a CEO. By that same logic, a rural medical posting ought to get more than the measly Rs10,000 that it commands. Double their wages, I say, to compensate for the intellectual isolation that doctors complain about. In this recessionary economy, that would make doctors flock to villages in droves.

Link: Original Article

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