PRIMARY HEALTH CARE
Prof B M Hegde
Vice Chancellor
MAHE University,
Manipal - 576119
Health is the first casualty in our villages and also in bigger cities. Whereas the latter have many large and small hospitals, both in the public and private sectors, vying with one another for patients, in addition to some really five-star ones for the upper income group, our villages, of which there are more than six lacks, have very little medical facility, not to speak of any health facility worth its name. Even the large cities have dismal health preserving facilities!
You may think I am splitting hair here. Far from it. The modern medical set ups, including the teaching institutions, indirectly stress on quick fixes for illnesses and do not really stress the need to preserve health. One could argue that the preventive health of the western variety, with its emphasis on very expensive preventive screening programmes for the so-called primary prevention, is top heavy and is not cost effective. By health in India I mean the basic amenities for a healthy living viz. clean drinking water, food uncontaminated by animal and human excreta and a clean environment for living. The latter collectively are referred to as primary health care for the purposes of this article.
By that definition health care is very inexpensive compared to the enormous cost of treating diseases, majority of which emanate from the unhygienic surroundings and the lack of immunity in the poorer sections. Poverty is the mother of all illnesses. One could see the dichotomy if one went into any five-star set up. While it is heaven inside a hotel there is hell just outside that, but one has to have the insight to see. Mere eyesight, with or without added assistance, would not see the squalor and the miserable state of those in hell.
Let us first concentrate on the
health of our villagers which, if improved, could achieve a quantum jump in our
productivity and could, as a byproduct, reduce our reproductivity as well,
without any special effort. The usual plea of the powers-that-be is that doctors
do not go to villages. We have to look into the root cause of doctors not going
to or sticking to the villages. Most of
the present day doctors come from urban background, even the small percentage of
rural students get urbanized by the time they go through the arduous course in a
medical school where the atmosphere is anything but rural. As such the young
medico is a stranger to a village and the life there. He/she has no roots
there. Neither is there any special incentive, although lip service is given to
that on paper.
The singular reason why even a
motivated and infracaninophilic young medico does not stick to the village has
to do with his training. The latter is heavily loaded with technology. Clinical
medicine, which flourished in the early part of this century, almost disappeared
from the medical school environment after the sixties and seventies, when modern
medicine went shopping to the market place riding piggyback on technology. If
one picks up any textbook of medicine every disease starts with technology and
ends with it. The medical student, therefore, gets convinced that technology is
an integral part of diagnosis and treatment. We can not fault him on that.
Although there are studies even in the nineties that have elegantly shown that
clinical medicine on the bedside is still the best; medi-business does not
highlight it. “Do it” “fix it” are the in thing in medical schools. Many
teachers are also convinced that without technology medicine can never be
practised.
The new medico in a village very soon gets frustrated and would suffer from guilt as he thinks that he can not deliver top class medical care there. This guilt kills and they soon leave the village by hook or crook. It is not that they are any the less patriotic than our petty politicians who shout from house tops that if only doctors went to villages India would be heaven. In the bargain if there were monetary allocation to the village centre politicians would find ways and means of siphoning their share of the booty! This hypocrisy kills even the last vestige of philanthropy in the rare breed of a passionate medico. Punishing them or making life difficult for them if they did not obey the political orders is not the solution, as they can not and would not practise medicine in a village with a conscience, mainly because of their present day training. If the doctor wants a CAT scan for every headache and an ECHO for even muscular chest pain (that his boss at the school insisted upon), he would go mad soon in any village!
What do we need in the villages for health care that is both universal and primarily effective in the virgin village population that has not been exposed to all the poisons that one gets in a large city atmosphere? In addition to the trio of basic requirements like clean water, food and healthy surroundings, they need a good human being that could understand them in times of distress and empathize with them. In addition, if that person could recognize rare instances of serious trouble, so that the sufferer may be taken without loss of precious time to the nearest hospital, most of health care in the village could be looked after.
If this individual could also
dole out harmless medicines for the minor illness syndromes, which form the bulk
of illnesses in the villages, our poor villagers would be ever happy and
grateful. Family welfare, nutrition and preventive vaccinations are other areas
where this individual could make an impact. School health of the routine variety
could also be added. This person would have to have a village background, and if
possible, from the same village. He/she would be the friend, philosopher and
guide to our villagers winning their confidence which in turn boosts their
immune system!
Who could that person be? There
is a move in the West now to empower nurses to become practitioners of medicine
in addition. These nurse practitioners have been found to be very useful to
manage many of the common illness syndromes. These form the bulk of illnesses in
society anyway. A recent Canadian study showed that while a doctor sees one
heart attack patient in the community he will have seen thirty thousand common
illness syndromes.
India has many nursing schools
and, if needed, they could be increased without much expenditure on
infrastructure even in Taluka places with a hospital there for their hands-on
training. It is possible to train our Auxiliary Nursing Midwives (ANMs) to
double up as nurse practitioners in the villages. The scheme could be devised in
such a way that girls with village background and some permanent interest in the
village could be selected for the course in the first place.
We need not follow the set
syllabus and teaching methods followed in the conventional schools. Interactive
problem based learning, with special emphasis on common illness syndromes, would
be very useful. Their usual duties are taught side by side. Even the existing
cadre could have a condensed course of a year to transform them into nurse
practitioners. One need not worry about their misusing the drugs. They are given
only very innocuous drugs, which even if given in larger than the usual dose or
given to the wrong patient, should not produce serious problems. They could just
handle analgesics, antipyretics, all the local topical creams, skin lotions,
vitamins, innocuous sedatives, anti-asthma medications by the inhalation roots,
and vaccines. Indian spices like ginger, onion, garlic, and peeper have been
found to be very powerful anti-viral drugs for most common febrile conditions
caused by viruses. They could not harm the patient, even when they are given to
the wrong patient. The common cold research centre in London has advised people
to eat Indian spicy food when they get a cold in the winter! We shy away from
our own golden remedies!
I am sure these make better health keepers than highly trained doctor-technicians, the latter being doers and interventionists. They think it is below their dignity even to think of these minor illnesses. Many doctors have not heard of the minor illness syndromes. They are not being emphasized in the textbooks and are not being used in their examinations. Today conventional learning has become examination oriented and not real life oriented. Once the examinations are over they are conveniently forgotten until the next examination. Feverish cold, caused by a virus different from the one that causes common cold, is the cause of the largest sick-absenteeism in the world. I should be surprised if you find a mention of that in any ordinary textbook of medicine for the final MBBS students.
Do the present day primary health
centres serve the purpose? Let me give you the simple economics of these centres
for the poor man in the village. The small town of Hiriradka, where I grew up,
has a primary health centre covering many surrounding villages. My village is
about five miles from the centre. When an elderly man has a headache in the
village, he has to either walk that distance (or take a bus nowadays) to the
town. His son is excited that the father is going to town and he accompanies
him. The two go to the town in the morning. They wait for the doctor and their
turn to be seen. Eventually the old man might get an aspirin tablet for his
tension headache costing five paise. The
old man and his son lost a day’s work, (one hundred fifty rupees) the bus fare
comes to twenty rupees, and while in the town both of them would have to
perforce eat in a restaurant there( thirty rupees). In short the aspirin tablet
has cost the man two hundred rupees.
If the mountain of health care
could go to Mohammed, things would be totally different. He could be given the
aspirin by the nurse practitioner in his field itself! This is the way it should
be in India where villages are far away from the primary centres. In addition,
the primary health centre of the existing variety could do very little extra
compared to the capabilities of the nurse. I am sure the powers-that-be would
not like this idea as this takes away their ability to handle the large budget
of the PHCs to siphon off their share of the booty. Unfortunately, we have
become so corrupted that we have totally lost sight of the common good in the
bargain.
I am told that in a particular
area where the central government has allotted three hundred fifty crores to a
particular cause, most of it is being siphoned off by the members of the
committee, in addition to all the Babus from top to bottom. Nothing seems to
have been spent for the real targets! Many of these people, I am told, think
that it is not a bad idea to have a fake NGO in their relative’s names to get
the largesse from the allotment for their future safety. I am sure there would
be opposition for the idea of nurse practitioner scheme from all quarters. Some
vested interests might argue that the nurse is not qualified to do what she is
made to do, little realizing that she is trained to do just that.
The government does not mind down
right quacks practising as registered medical practitioners. They need to get a
certificate from a revenue officer. The above scheme would put an end to that
kind of nefarious activity. Where we need strict vigilance we do not seem to
have it. There are no rules to see that spurious drugs do not get sold as long
as the manufacturer calls it Ayurveda. While we have too many rules for modern
drugs, there are hardly any rules for the so-called Ayurvedic drugs. The word
Ayurveda is being misused for business by all and sundry. The genuine Ayurvedic
preparations are so difficult to make that some genuine manufacturers find it
almost impossible these days, what with all spurious ingredients in the market.
We need to regulate the drug manufacturing irrespective of its label and also do
the same for the training requirements of the RMPs in the country.
A revenue officer certainly is not competent to certify him fit to be let loose on the gullible public. Most of them might use harmful drugs, like steroids, for quick relief without realizing the potential long-term dangers. This kind of activity goes on in our far-flung villages more than in cities. Good health care in the village would dampen their enthusiasm to a great extent.
I hope some thinking leaders in society would give a serious thought to this idea. Let there be a national debate and something fruitful might emerge. I do not want to claim that this is a perfect idea. We could always modify and see how it fits. While the affluent West wants to change from their top-heavy medical system to something less expensive, we in India do not bother to audit our systems at all. Once put in place they are presumed to be good for all times to come and under all circumstances. “Let noble thoughts come to us from all sides.”