Andhra Pradesh: the state that dared to train ‘quacks’ in medicine
https://mosaicscience.com/extra/andhra-pradesh-quacks
There remains considerable resistance in India to the idea of training the country’s abundant ‘quacks’ to provide proper medical care. But the state of Andhra Pradesh has been there and done that.
In 2009, around 56,000 ‘rural medical providers’ (more than half of
the total number in the state) signed up for a six-month training
programme in medical skills run by the state’s paramedical board. They
received three months of classroom lectures, and were also put to work
in hospital wards, accompanying doctors on their daily rounds. A number
of the students also assisted doctors in the state’s 104 rural ambulance
services.
Although the programme was aborted in 2012, it’s an interesting case
study for what such training can achieve. It is impossible to assess
this objectively without a randomised trial, but training has certainly
made informal providers more aware of the damage their negligence can
cause.
Choppari Shankar Mudiraj, a rural medical practitioner from Khammam, a
city in Telangana, now uses disposable syringes instead of disinfecting
reusable ones with Dettol. He also provides newly prepared intravenous
equipment for each patient, even if this takes an extra half an hour.
Most importantly, Mudiraj says, he refers patients to doctors sooner
when his own treatment isn’t working. “We used to treat patients for up
to one week. But now, we don’t treat them for more than three days.” S
Venkat Reddy manages a hospital manned by several qualified doctors in a
slum occupied mostly by construction workers. He says the programme
taught him how to give correct first aid to a patient with a spinal
fracture: “We learnt how to make that person lie down; turn him, shift
him etc. I learnt that you cannot make him sit anywhere.” And Choleti
Balabrahmachari, an informal provider from the Rangareddy district, has
eschewed the use of metamizole, a drug he formerly prescribed frequently
for stomach aches and headaches, because of the risk of severe side
effects.
The programme didn’t change all students’ practices completely
though. Although it required all participants to stop using the prefix
‘Dr’, several practitioners, including Reddy, still have it on their
business cards. (The Andhra Pradesh paramedical board that ran the
course has not been able to enforce this rule because the programme
ended prematurely. Besides which, the participants were never officially
registered with the board as paramedics.)
But a much bigger worry is that rural medical practitioners may
attempt complicated surgical procedures or prescribe strong antibiotics
and steroids, practices they are known to indulge in. The chairman of
the Andhra Pradesh Medical Council, E Ravinder Reddy, opposed the Andhra
programme – and argues that it’s highly unlikely informal providers
will alter their behaviour after a matter of months receiving similar
training. “They are already violating rules. [After the training] they
will violate them even more,” he says.
The practitioners I spoke to vociferously disagreed. They say such
malpractices are the work of a minority – and that senior organising
bodies in the community view them sternly. Yet everybody is punished by
overzealous government officials looking for scapegoats.
Balabrahmachari says it is easy to harass rural medical practitioners
without taking into account the circumstances in each patient’s case.
“Sometimes, when a person has a heart attack, his family brings him to
us and demands that we give him intravenous glucose. He may not even
have a pulse or may have very low blood pressure already. But the family
forces us.”
I asked Balabrahmachari and others about another popular accusation:
commission – or rural practitioners taking a cut from qualified doctors
for referring patients to them. He had seen no evidence of this, but did
say some circumstances could be misinterpreted. “Suppose I take a
patient to an excellent hospital,” he says. “They give me bus-fare
because I have closed my shop and haven’t even eaten food the entire day
to get him there. He may give me 50 rupees to eat food.” P Hanumantha
Rao, a provider from the Nalgonda district of Telangana, has a
contrasting view. “There are nameless rural medical practitioners in
tribal areas who may take more money and give unnecessary injections.
There are 10 per cent such people definitely. But awareness programmes
and training have made a lot of difference.” G Balraj, a graduate in
biotechnology from the Armed Forces Medical College in Pune, worked at
an Indian army blood bank for seventeen years before starting a medical
practice. He explains that associations of informal providers fine their
members for taking such ‘kickbacks’ – and expel them if it continues.
“Nobody is taking [commission]. If I send my patient to a doctor, I tell
him on phone: sir, whatever commission you want to give me, please
deduct from [the patient’s] bill.”
According to these practitioners, patients rarely complain about
them, because they know a doctor wouldn’t attend to them in the same
way. Says Balabrahmachari, “Yesterday, while a man was washing crops in
water, he got bitten by a snake. The village sarpanch [elected
head of a village government] called me to attend to him. I tied a
bandage and brought him to Osmania hospital. Would an MBBS
[degree-level] doctor do this? By the time the patient would have
reached Hyderabad, he would be dead already.”
S Venkat Reddy adds, “The people of Tanda [a region in Telangana
where Reddy practises] have never told us to shut down, because they
don’t even have access to buses for 13 km. I have to ride a cycle, wade
across two streams after bundling my clothes on my head, borrow another
cycle at the other end and ride again to reach the patient and give
medicine.” That is why the families in Tanda respect and trust him, he
says. “The government harasses us, but the people never do.”
No comments:
Post a Comment