The doctor keeps away

Junior doctors and medical students are going on strike all over the country. This is not a new phenomenon, but this year they seem to be occurring with more regularity, or at least receiving more media attention.

In January the junior doctors and medical students of Uttar Pradesh struck work and even resorted to violence. The reason - a clash between a group of junior doctors from King George's Medical University (KGMU), Lucknow and police recruits on a train. This strike spread into other medical colleges in the state and lasted a week, and the government eventually had to ban the strike under the Essential Services Maintenance Act (ESMA). In late February the junior doctors of Mumbai struck work because of multiple events in which patient's relatives and friends came inside the hospital wards and beat up junior doctors. The doctors complained of lack of security, and pathetic work conditions; the strike lasted nearly two weeks, crippling work in Mumbai hospitals and in other parts of Maharashtra as well.

In early April, junior doctors in Andhra Pradesh struck work for twelve days demanding that quota for in-service candidates in PG exams be reduced. In mid April the junior doctors and medical students in Delhi started their protests against the proposal to increase reservations in institutions of higher learning. At the time of writing in mid - May this anti-reservation protest had spread across the country and doctors in far away Bangalore, Ahmedabad, Kolkata had also joined in this agitation which is meant to preserve 'merit' against 'reservation'.

Today as I sit down and try to understand the reasons and justifications of strikes by junior doctors I am reminded of my own dilemma as a house-surgeon in a medical college in Kolkata (then Calcutta) twenty years ago. Some of the questions that seem pertinent today are:

• Do junior doctors strike more often than other young professionals?
• Are their grievances justified?
• Do we need to preserve merit in the medical profession to keep it robust and best serve the needs of the nation?

Strikes by junior doctors do seem to be more frequently visible than their counterparts say - junior engineers, junior managers or junior lawyers. One of the reasons is perhaps the fact that most junior doctors are employed or under training in government hospitals, unlike other junior professions, who are typically employed in private industry. It should also be pointed out that junior engineers are usually diploma holders and not graduates. Graduate engineers usually aspire for private sector jobs or for further training in management. Freshly graduated managers from premier institutions on the other hand make news for securing jobs with record salaries during campus recruitment.

Thus students from similar socio-economic and academic backgrounds who graduate from medical colleges, engineering colleges or management face radically different employment prospects when they graduate. For freshly graduated doctors spending some years as junior doctors is not so much an employment, as it is a long period of training before they can become the specialists that most aspire to be. Government hospitals, especially the larger teaching hospitals, depend upon this cadre of low paid trainee specialists to do the bulk of the clinical work, providing these doctors with valuable work experience and skills but at a relatively high cost - eg. heavy workload, low pay, and poor work environment. Graduate engineers and managers from similar academic backgrounds, on the other hand, complete their graduation more or less fully trained to join lucrative jobs in a rapidly growing and liberalized economy.

The story is somewhat different for lawyers. Many young lawyers do not come from the same socio-economic and academic background as engineers or managers, and may have different aspirations. The junior lawyers gain experience working with seniors but this is almost always an individual and private arrangement where striking can hardly be seen as an option.

I remember my days as a junior doctor, quite fondly. I picked up most if not all my medical skills during this period. It was a heady experience to successfully deal with a perforated appendix, a severe shock or an ectopic pregnancy. But back then too, junior doctors felt exploited when we had to go through straight 48-hour shifts of emergency duty every six weeks, or when we were woken up night after night by the ward attendant to answer the call-book, while we were sharing a room with three other colleagues. It seems now that we had to eat, drink and sleep in the hospital most of the time for those two years. And at the end of the month the measly 450 rupee stipend (later revised to 600 after the strike) was not enough to cover the mess bills, and we had to ask for money from family members to cover even our essential expenses.

Today the workload in government hospitals has increased, while government investment in health care having come down significantly, worsening an already bad situation. The junior doctor is restrained from being able to provide the most appropriate treatment by lack of cutting edge technology (which was earlier available in government facilities first) and the patients' inability to pay. Hospitalisation costs are known to reduce many families to penury. The 'patient party' has over the years also become more assertive, but young medicos are not formally equipped with any inter-personal skills. The low compensation that junior doctors receive is also a serious disadvantage in an age of disposable incomes and increasing consumerism among youth; the resulting financial pressures, added to poor interpersonal interaction with hospital staff, can lead to frayed tempers.

Having commiserated with some of the grievances of junior doctors I would like to now draw attention to the issues of merit and reservations, which are poised to paralyse the government hospital system in many parts of the country. The medicos (along with many other professionals) have argued that the added reservation for socio-economically backward groups will jeopardize the standard of professional competence and the ability of the profession to serve the needs of the nation.

Medicine for the elite

To judge that, it would be useful to first examine how effectively the present training system for doctors serves the medical care needs of the nation. Training of indigenous doctors exclusively in western medicine began in India in 1835, when the British rulers simultaneously started medical colleges in the Calcutta, Bombay and Madras presidencies. This marked the beginning of official patronage of western medicine for the natives. Though these medical colleges were open to youth of all castes and creed they created a new native elite of doctors, many of whom started to go to Europe to gain advanced training. The medical needs the of urban elites and of the armed forces (both native and British) were soon served through a large network of well- equipped civil and military hospitals which were run by large pool of native doctors trained in European medicine. At the same time a large part of India was either excluded, or even resisted the influence of western medicine.

At the time of independence the Bhore Committee (1946) made its revolutionary recommendations for remodeling health services in India. Among its recommendations for integrating preventive and curative medicine at all levels was the proposal to train 'social physicians'. Since then many other committees like the Kartar Singh Committee (1973), Shrivastava Committee ( 1975), Bajaj Committee ( 1986) have been convened to recommend changes in medical 'man-power' training and orientation to serve the health needs of the nation. However the changes have been cosmetic as far as doctors are concerned, and even today the medical education system trains medical practitioners who are best suited to serve the medical needs of the urban elite and through very well equipped hospitals.

Oddly, the legacy of medical training model which the colonial masters left behind continues to provide handsome returns for the home country. It is not surprising that the British National Health System (NHS) is supported by more than twenty five thousand doctors of Indian origin who received the basic medical training in India. While this can lead to a valid demand that the Indian tax-payer stop subsidizing the health care costs in Britain, it also forces us to examine the utility of the present (state-subsidized) medical education and training system in responding to the health care needs of hundreds of millions of non-elite Indians. The very poor health outcomes (eg. high infant mortality rates, low immunization rates, high maternal mortality, low safe delivery rates, high rates of communicable diseases and associated mortality) raises questions about the effectiveness of the dominant western medicine in providing for the health needs of the poor in India itself, whatever its achievements in the UK.

The results of a nation-wide health facility survey shows that in the states with the poorest health indicators, the presence of health personnel at their place of work is also among the poorest. An assessment by the consultancy firm McKinsey, which shows a shortfall of over ten thousand public health specialists in the government sector alone, indicates that the post-independence health training model has been woefully inadequate in assessing and addressing the health care needs of the country.

This is the real worry that any strike should alert us to. Considering that the nature of training for doctors as well as the large number of doctors trained through it have not been sufficient for addressing the health care needs of hundreds of millions of 'non-elite' Indians, the discussion on the importance of merit is of little significance for the health care needs of the nation. Reservation for the socially and economically backward may allow some of the disadvantaged to gain skills that they may use to provide services to their own communities. But again they may not, and these doctors too might end serving an already health-privileged portion of the population, or leave for more lucrative shores.

Until a rational and effective health care delivery system is planned which includes the interest of the poor, and personnel trained accordingly and compensated fairly, the highly specialized curative needs of the poor will from time to time be held hostage to the aspirations of the junior doctors. While I had resolved my dilemma twenty years ago by not joining the strike, I wonder whether such spaces for dissent exist today.