Express Townhall: ‘Health sector has been neglected, but look how nation came together during Covid’

Anuradha Mascarenhas: Why has medical education remained so unaffordable in the country?

Health sector has been neglected. Look at the budget which was allocated to health. Slowly over time, public health got quite eroded. This became quite obvious during the Covid outbreak. But at the same time, look at the resilience and energy with which the nation came together. From the doomsday that was predicted for India, we have come out as winners with our own vaccine and the largest vaccination strategy.

Coming back to your question of medical education, I think, with competition and demands increasing, the government could not provide medical education at subsidised rates beyond a limited number. The result was that it encouraged and permitted privatisation. Private medical education is not a bad thing but it does lead to some kind of a business model. I guess that is where things began to go different, and today many students have to go out of the country do study medicine.

Anuradha Mascarenhas: You had said earlier that medical students who have returned from war-torn Ukraine cannot be included in the system as it would be unfair to others. What is being planned for them?

In that regard, Maharashtra has taken some early decisions. When students were coming back from Ukraine, the state minister for medical education told us to look at ways and means of helping them. So, we got into action immediately and started collecting data on these students. We expect that there would be about 3,000 students from Maharashtra.

The only way to reach out to all students, and this is something that Covid has taught us, is through digital technology. Some of the universities have actually started their own online courses. From April 1, we would probably start online classes. They would also be provided with teaching material which is curated and would include built-in assessments. So that is something we are going to make once they register with us. MUHS has already gone online.

Also, I have spoken to deans if we can run small workshops for these people on weekends or evenings, to give them a little idea of a clinical exposure. We have studied in depth the Ukraine syllabus as well as interacted with students. Their methodology of teaching and curriculum is slightly different. They do it more through simulations and there is not much direct interaction with patients. So, if we can ensure some amount of patient-related bedside teaching, it would be value addition. And when they come back, whenever they finish their course, they would be able to find it easier to do the foreign medical graduate examination. It would also go a long way in giving them a reassurance that people care.

At the moment, many of them are quite traumatised. I have interacted with some students directly. Some of them had to walk for long distances, some of them saw bombs falling next to them, nearby. They are at the moment quite shaken up, so this would say that OK, there is someone caring and we can use our time effectively.

I have interacted with students who are back from Ukraine. Many of them are traumatised. Some of them had to walk for long distances, some of them saw bombs falling next to them, nearby.

Parthasarathi Biswas: What is a healthy doctor to population ratio, and healthy medical college to population ratio? What is the shortfall in the medical colleges that we are facing?

The WHO standards say that you need about one doctor for every thousand people. We are nowhere there right now, but we are improving. We have added large numbers of undergraduate seats in medical colleges in the last three-four years. We now have almost 90,000 seats. And many more are likely to be added in the next few years. More government colleges are being opened. Hopefully, in the next five to ten years, we would be able to reach the international standards.

But just adding seats is not enough. About 80 per cent of our doctors are in large cities, and nearly 80 per cent of our population lives outside of these large cities. For equitable access to health services, this also needs to be addressed.

Amitabh Sinha: Why is medical education so costly?

It is the cost of running an associated hospital. Except for the dissections, and a little bit of lab work, everything about medical education happens in the hospital. If you are using a 400-bed hospital, there are associated health care costs. In the government medical colleges, the costs of running a hospital are borne by the government. But in the private sector, a part of that cost gets directed to the students’ fees.

Amitabh Sinha: The pandemic, the students returning from Ukraine, and recent circulars asking private medical colleges to offer half their seats at government-mandated fees have all put focus on the state of medical education in the country. What are the main reforms being brought in this sector?

Several reforms are being tried. As I said earlier, the number of seats in medical colleges is being increased. In some cases, seats have been doubled in the last few years. The shortage of faculty is being addressed. Unlike many other courses, medical education can not be provided online. That is a constraint. So, we need to concentrate on developing and getting the right kind of people to teach. An academic career in medicine must be made more lucrative, and some efforts are being made in that direction.

One big reform has been the setting up of AIIMS like institutions in several places. The shortage of faculty is still a problem here, and that is being addressed. The biggest challenge is to maintain and improve quality.

One interesting reform being tried out is the district residency programme. This was started with two things in mind — to improve patient care and address the shortage of doctors. If we can get all the post-graduates from the medical college to spend at least three months by rotation in district hospitals, then it can be very useful, not just for the community, but for the doctors as well. Students will learn what is happening in the community, and get sensitised to community needs as well, rather than be focused only on tertiary healthcare in big hospitals. In the long run, if this residency programme is successful, infrastructure at the district hospital can be upgraded so that you can probably accommodate 30 per cent more post-graduates.

Dr Kanitkar is one of the most influential voices in the country right now on medical education. (File Photo)

Alifiya Khan: Last week Dr Nitin Karmalkar, the former MUHS VC, had talked about his efforts to increase a few seats in a medical college. He said it took almost a year and he realised that Medical Council of India guidelines were a big bottleneck. How far do you think red-tape has to be blamed for creating a shortage of seats in medical colleges, and what is the way around it?

I agree with you that we have to increase undergraduate seats, but increasing undergraduate seats is very human resource intensive. Undergraduate teaching needs faculty in pre-clinical and paraclinical stages and today that is the bottleneck. So, we would be jeopardising quality for quantity if we keep opening medical colleges in every district.

We will have to think out of the box. Even technology solutions have to be explored. Online classes, though not ideally suited for medical education, can be tried. One professor instead of teaching 100 can maybe teach 1000. His lectures can be made available to everyone while a younger, less experienced faculty can facilitate the learning process offline. That can be one way of doing it.

The second thing is allow the students to go in for post-graduate studies immediately. With medical knowledge advancing at a fast pace, 4-1/2 years of undergraduate study is not enough to make students independently handle all kinds of emergencies. The entry to post-graduate courses is extremely tough. But ideally, I do believe, that there should be one post-graduate seat for every seat at the undergraduate level.

Pallavi Smart: There was a plan to talk to east European universities for students returning from Ukraine, which also included universities in Russia to accommodate Indian students. What is the status of that proposal?

We have not yet reached out to those countries but we do plan to. That is our option two. Option one still is to facilitate the students to get back to their universities in Ukraine as soon as the situation there is feasible to resume studies. That would be their comfort zone. They have learned the local language and they feel very comfortable.

Parthasarathi Biswas: What is your opinion about mixopathy?

There is nothing like mixopathy. There is however a definite scope for an integrated approach to wellness. What is needed today is to promote research and create integrated best practice guidelines and we can start with the 10 commonest problems. We are all saying India is going towards a non-communicable disease outbreak where hypertension, diabetes, kidney failure will rule the roost. One system of medicine might not offer all solutions. If we have an integrated approach, I think that can be useful. It is not mixopathy but integration of different medicine systems and I think there is a scope for that.

We are all saying India is going towards a non-communicable disease outbreak where hypertension, diabetes, kidney failure will rule the roost. One system of medicine might not offer all solutions. If we have an integrated approach, I think that can be useful.

Anjali Marar: Nursing education is equally expensive. They start their practice here but soon move abroad. How do you view this and what can be done?

Yes, I totally agree. Several girls who undergo education for nursing come from a lower socioeconomic background. They really need support. They are very hardworking and excellent girls who come forward for training. But we do not have adequate nursing colleges. And more important, again the quality because as against medical colleges where we can try hands on in skills that it requires to be trained for them, and is very, very tutor heavy. Also our girls are very sincere and work with dedication. The world wants them but they can certainly pay them better.

Sushant Kulkarni: You have seen generations of soldiers and officers in armed forces. How is the health scenario in the armed forces evolving? What is the way ahead?

I think health and fitness is the basic ethos that remains. You have to have a fit mind in a fit body and it is one organisation which encourages you, gives you time and infrastructure and gets you to make it a way of life. After 40 years of being in uniform, I still get up at 6.00 am and do a 5-6 kilometre trek, walk into the hills of Nasik. It becomes your lifestyle. So I think that has not changed over time. Yes, standards have changed. So if in the country there is an increased incidence of non communicable diseases, we are also seeing it in the armed forces. Definitely it is slower, but yes it is increasing at a slow pace because of changing lifestyles, changing food habits.

Manoj More: What is your view about the way the medical fraternity handled Covid-19 patients. There was so much confusion among doctors as treatment guidelines were being revised.

The world was confused. We were probably a little better off. Our mortality figures were much lower in spite of all the chaos and confusion. And I think there were two main really important reasons. One, the waves came much earlier in the USA and Europe. We learned from their mistakes. For example, they were doing elective ventilation. We realised patients were actually worsening with lung trauma, so our protocols changed. We learnt the art of non-invasive ventilation.

I think it was a huge learning curve and doctors were no different because it was not that you knew everything. You had the tools that if this happens, you do this. But those tools did not work sometimes. It was such a rapidly evolving situation. When you frame guidelines, you have to get through the evidence and then say, OK, let’s do this. But by the time the evidence was collected, it was time to change the guidelines because of fresh developments. We were expecting the doctors to be clinicians, paramedics and data entry operators.