Monday, October 20, 2008

A medical student’s journey towards working for health and social justice

Every Indian medical student is a witness to social injustice on a daily basis. Everyday they see patients denied necessary medical care because they are too poor to afford it. Everyday they examine sick patients who are too powerless to tell them to leave them alone. Most practical teaching happens only in general wards where the poorer patients are admitted. All medical students experience the disrespect, misunderstanding and callousness that are typically characteristic of such wards. There comes a point during every medical student’s life when he or she begins to start asking questions. Why does modern medicine have to be structured like this? Why does this mother who obviously loves her little baby refuse our advice to admit her in an ICU? Why are the majority of patients who would benefit from treatment unable to afford it? Why do drug reps spend so much on my professor? Why has this man come to the hospital so late? Is their no other way to gain practical experience but to be the thirtieth student to palpate his painful swelling today? As with most hard questions there are easy answers designed to satisfy the casual seeker. Modern medicine is a storehouse of good efficacious treatment protocols but poor patients are too stupid to realize that. The reason they are poor is because they are stupid, lazy and persist in having a lot of children. Doctors work hard and deserve 5 star dinners with free booze on a monthly basis, refrigerators and vacations to Bangkok. This has absolutely nothing to do with why medicines are so costly. Poor patients who refuse to be examined by medical students are ungrateful. Only Gandhiji and Munna Bhai need worry about them. It is indeed surprising that so many students accept these flimsy untruths without outwardly feeling too uncomfortable. Yet in every batch there are a few that persist with their questions, compelled to seek out uncomfortable truths and act upon them. They soon realize that you don’t have to go far to find conflict and injustice. Everyday people suffer and die meaningless, stupid deaths due to man-made poverty and ill health right at our doorstep. Every doctor and medical student potentially works in an area of social conflict. This article is about students and young doctors who choose to face up to the fact that they all work in such an environment of immense inequity and social conflict and who realise they have the power to do something about it. It is about the choices with which they will have to make, the obstacles they are likely to face and possible solutions to them. The article is based on my own experiences as a medical student as well as those of a number of committed students and doctors, both young and old whom I have had the good fortune to meet. *Loneliness and bewilderment.

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*Any medical student questioning the system which he or she is becoming a part of will be initially faced with a feeling of loneliness. They seem to be the only one who feels that something is terribly wrong. Long standing friends and roommates will suddenly seem distant and disinterested in this new found interest in social justice. People will term their questioning a ‘phase’ which they will soon snap out of. Soon enough they will be told that the real world is a harsh one and poor people will always die. Only dreamers think otherwise. Such indifference can be bewildering and infuriating and often leads to self doubt and the feeling that just maybe you are the one with the problem. While at the gut level it is quite obvious that something is wrong initially it is very difficult for a troubled student to describe what exactly it is because he or she does not know how to put it into words. All medical undergraduates have had a school education that consists only of basic sciences with no significant component in social sciences. They are hence able to describe physical and medical phenomena in great detail but fumble when it comes to social phenomena. The same student who can go into the details about exact nature of the lung condition of a small baby cannot describe why it is not only morally reprehensible but also legally wrong that she be denied basic care. Their professor might put forward the fundamentally unsound argument that if they did not support the pharmaceutical industry then thousands of jobs would be at stake but since the student has no knowledge even of basic economics he or she would be unable to rebut it. They will also soon realize that their professors of Community Medicine also have little or no useful knowledge of economics, politics and social science and are just as ill equipped to describe the reasons for poverty and indebtedness in rural India or the reason drug prices are so high.

*Finding solidarity and being different.*It often is just a small offhand mark from a senior, the chance attendance of a guest lecture or an article in the mainstream media through which a questioning student realizes that he or she is not alone. There are indeed a number of people all over the country and elsewhere who are deeply troubled by the state of health and health care in India. In every major city there are individuals and organisations that are dedicated to studying the Indian health system and acting upon the inequities and injustice that they witness. It is a strange phenomena that in India most good path breaking research and experiments in community health happen outside the academic departments of medical colleges. The academic community is by and large an uninspiring lot and consequently a majority of students find college taught Community Medicine to be dry and boring and of not much practical value. The small but fiercely passionate activist and NGO community is by contrast is immensely inspiring for a young student seeking answers and it is here that most of them eventually gravitate. It is at such institutions that they receive their first lessons in the new paradigm of health as a political and social issue. By this time friends and classmates would have this noticed this strange new tendency to ask a lot of uncomfortable questions, talk about justice and health and associate with a lot of kurta-clad jhola-carrying persons. Invariably some version of the “do-gooder/dreamer” tag gets attached to the new socially conscious student. Eventually most learn to wear their new image lightly and soon begin to enjoy the feeling of being different. *Choosing a vocation and leaving home.

*College is a time of great freedom for most students especially if they stay in a college hostel away from home. Most students who begin to get involved in issues of health and social justice draw heavily on this freedom. The unusual books they read, the unusual people they meet and the places they visit are all tolerated as part of the necessary space granted to every college student before they are once again called back to conform to the conventional aspirations of a well paying job, spouse and children. Especially towards the end of their undergraduate course subtle or explicit suggestions are made from well meaning parents and peers to put behind them their ‘social justice phase’ and to concentrate on more important issues of post graduate competitive entrances, marriage and financial security. It is generally now that most students will have to first personally decide whether they do indeed have a vocation or whether their college based exploration was indeed only a ‘phase’. The temptations to yield to a life of elite comfort are indeed great even if it also means simultaneously choosing intellectual and moral oblivion. For those who decide that they indeed have a vocation to serve the poor and the oppressed the next step is to communicate this decision to friends and family. This can range from being a completely positive to a completely negative experience. In extreme cases a student may be asked to choose between family and vocation but in most cases things are settled more amicably. Indeed it is very possible to live a vocation of service while raising a family and earning a reasonable salary in an area of relative convenience and most parents eventually get around to accepting that. It is now that the student can finally begin to leave behind the lifestyle and values in which he or she had been brought up in and begin to live the life and values had he or she voluntarily chooses. This is a symbolic leaving of the home. In some cases it may be also accompanied by a physical leaving of home or hostel at the end of their MBBS studies to live and work among those in need.**

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*Exploring unfamiliar territory.*Exploring issues of health and social justice will eventually take the student or young doctor to poorer, exploited communities where such issues hold great relevance and the need for them is greatest. Working in such areas is an extremely enriching experience, enabling one to actually see and feel issues which might have only been theoretical within the safe, sterile confines of a medical college campus. Issues and debates within the public health field take on a practical clarity and soon one it is easy to distinguish between genuine, relevant theories and debates and self serving intellectual blah. Young doctor are indeed privileged that they possess knowledge and skill that are of great need in many areas of the country. One does not have to go to remote rural areas in India to find areas of great medical need. Urban slums across the road from medical college hospitals often have equally bad access to good, effective care. The area and conditions in which a young doctor chooses to work are often determined by a number of personal and social factors. However no matter what the constraints are it is hard to find an area in India which is free of social conflict and man made suffering. Living and working in such areas also brings its own set of small day to day challenges. Students or young doctors might not be familiar with the local language and might have to make a special effort to learn it. The food and local customs may be different from what one is used to. If one chooses to spend time in rural India then often it will be impossible to frequently communicate with family and friends and loneliness is certainly an issue. City born young doctors may have to get used to snakes, spiders and hordes of insects that regard you as a lump of delicious protein. Simultaneously the sheer immensity of injustice and ill health which had been tucked away from sight until now is sometimes difficult to take in. An issue such as access to comprehensive health care suddenly moves from the comfortably theoretical level to the deeply personal when a small child you have grown to love dies of a preventable cause. As one delves deeper into the cause of such conditions one will also have to confront the fact that a good number of the perpetrators of such injustices in fact belong to the families and communities which are rich enough to send their children to medical colleges. *Seeking meaning in what you see.
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*Practical experience of the realities of health and justice for the majority of India is not enough to be able to effectively work as an agent of change. It is important to possess the theoretical knowledge and practical methodology to be able to delve to the root causes of problems in order to make long term changes. After spending time experiencing the ground realities of health and social injustice a young doctor may need step back a little to be able to understand the boarder picture in which such local realities are situated. There are two broad options for further postgraduate study. One can either specialise in a clinical field or in a field related to the broader determinants of health such as public health, epidemiology, health policy, anthropology, political economy or social theory. Doctors need a good understanding of both broad areas and specialising in one does not mean that you can disregard the other. Some more academically oriented doctors manage to eventually specialise in both broad fields. For clinical specialties the conventional path is through highly competitive postgraduate entrance examinations that usually require at least a year or more of cramming to crack. Most postgraduate courses are increasing beginning to concentrate on high tech care for the rich. However there are now a host of newer options which aim to enable a student to gain the required skills required to practice in areas of need while simultaneously allowing them to study broader determinants of health. Notable among them is the DNB Rural Surgery course designed by the Association of Rural Surgeons of India. It is also ironical that for those who can afford it, it is sometimes easier to gain admission to a post graduate course in certain clinical specialties abroad than in India. There are a lot of international courses that attempt to synthesise clinical teaching with social medicine and it beyond the scope of this essay to enumerate them all. Many of them offer generous scholarships especially to students with a proven track record of working in areas of need. The options for those wanting to further specialise in fields relating to broader determinants of health is rather limited within India. The Indian academic community does not have a very good track record of good research and teaching in fields of public health, health systems and policy research, public health anthropology and sociology. There are a few good institutions such as Christian Medical College in Vellore, Centre of Social Medicine and Community Health at Jawaharlal Nehru University in Delhi and Achutha Menon Centre for Health Science Studies in Thiruvananthapuram but the bulk of postgraduate MD Community Medicine teaching in medical colleges is very mediocre to say the least. The new trend of a number of MPH courses starting up all over the country spearheaded by the Public Health Foundation of India promises the availability of some basic public health education but it will probably be years before the academic public health community become vibrant enough to sustain more flexible and highly specialised programmes. The other option is for one to pursue studies abroad and there are indeed a good number of programmes in Europe and North America to choose from. There is a tendency to be uncomfortable with knowledge and skills learned in Western universities in this post colonial era. However the discerning student will soon be able to separate out Western economic and foreign policy which is indeed devastating to the health of millions around the world from Western public health academic teaching which is much stronger on the social, cultural, economic and political components of health than their Indian counterparts. Here too there are a number of opportunities for scholarships and research grants. The activist and NGO community in India who along with the government public health system constitute the real ground level innovators in community health in India have of late also started organising workshops, short study courses and fellowships for those interested in a more systematised introduction to community health in India. Notable among these is the Community Health Learning Programme for Young Professionals offered by Community Health Cell in Bangalore. *Finding your place in the movement.

*Having gained both a good practical understanding of the ground reality of health in India, a relevant skill set and a firm theoretical foundation it is now up to the young doctor to find a niche within the health and social justice movement where he or she will be able to be achieve personal happiness and social relevance. It may be as a primary care physician in a remote rural area or a health policy researcher in an urban area. The journey does not end here. In fact it has just begun. To quote from Harrison’s Principle’s of Internal Medicine, “No greater opportunity, responsibility or obligation can fall to the lot of a human being than to become a physician. In the care of the suffering he needs technical skill, scientific knowledge and human understanding. He who uses these with courage, with humility and with wisdom will provide a unique service for his fellow human and build an enduring edifice of character within himself. The physician should ask of his destiny no more than this, he should be content with no less.”
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Lalit December 2007Sittilingi, Tamil Nadu

1 comment:

OMESH said...

Dear Sir,
This is an interesting article and most important is to actually be able to make a difference in the lives of the poor which is dificult especially in a cynical society of middle class of India.
I have tried it in many cases and success was not easy, those who are opposing are the ones who donot need these initiatives but donot want them to benifit the poor, may be they like status quo.
dr. Omesh Bharti