India is training ‘quacks’ to do real medicine. This is why
https://mosaicscience.com/story/india-quacks
3 NOV 2015
Priyanka Pulla asks if there can ever be legitimacy in ‘quackery’.
Aditya Bandopadhyay has treated the sick for more than
twenty years. He works in the village of Salbadra, in the state of West
Bengal, India. He has no degree in medicine.
Bandopadhyay was trained in the rudiments of clinical medicine by a
homeopath who also happened to practise modern medicine on the side.
Bandopadhyay charges every patient just 10 rupees (15 US cents) per
visit, notching it up to 20 rupees for house calls. His arsenal includes
antibiotics, intravenous saline and chloroquine phosphate for the viral
fevers, dysentery and malaria common in the region. But he doesn’t
always give his patients medicines; sometimes he just advises them on
personal cleanliness. “Tribal people are not very hygienic,”
Bandopadhyay says. So he teaches them how to purify water, sprinkle DDT
during outbreaks of mosquito-borne disease and use clean sanitary towels
during menstruation. “If they come to my chamber, I first give them a
dose of hygiene, and then give them a dose of medicine,” he smiles.
Bandopadhyay is a rural medical practitioner, one of an estimated 2.5
million in India who practise medicine without formal training. Among
his ilk are people who have worked as assistants to doctors, those who
inherited the use of traditional systems of medicine such as Ayurveda
and homeopathy from their parents, and graduate lab technicians who
switched to healthcare. None of them are doctors by any definition. They
are entrepreneurs who have picked up bits and pieces of medicine
through informal apprenticeships and built up large practices on their
own. Or, in the words of the Indian Medical Association, they are
‘quacks’.
Yet their popularity remains steadfast in their communities. They
fill a void in India’s healthcare system that cannot be ignored. And
rather than mocking, berating and clamping down on them, at least one
organisation is planning to harness them.
For the past couple of months, Bandopadhyay has attended a training
programme that may transform the way he goes about his work. It teaches
rural practitioners the basics of medicine, from human anatomy to
pharmacology, giving them the theoretical knowledge that they lack. Run
by the West Bengal-based nongovernmental organisation Liver Foundation,
it aims to equip people like Bandopadhyay with the skills to treat
acute cases of common illnesses, and, crucially, help them judge when
their patients need to see real doctors.
When he graduates, in about seven months’ time, Bandopadhyay will
receive a title showing his new paramedic status: Rural Healthcare
Provider. But there are also two forfeits. He will have to stop
prescribing most Schedule H and Schedule X drugs, medicines that only
doctors are allowed to prescribe in India. While he will be allowed
limited use of a few antibiotics, such as amoxicillin and doxycycline,
in life-threatening conditions, stronger antibiotics such as ceftriaxone
will be out of his reach. He will also have to drop the prefix ‘Dr’
from his name, a title currently enjoyed by many rural practitioners. In
effect, Liver Foundation’s controversial programme will demote its
students, from self-styled and self-taught doctors to health workers who
can only treat the simplest of illnesses.
The idea of training rural medical practitioners ignites acrimonious
debate in India. On one side are the Indian doctors, and more
importantly the associations that represent them, such as the Indian
Medical Association. The Association’s official stand is that training
such ‘quacks’ is tantamount to legitimising them. It says rural
practitioners and their half-baked medical training have caused enormous
harm to patients and public health as a whole. The blame for many ills –
whether irrational prescriptions of antibiotics, botched surgeries or
corrupt practices, such as demanding bribes from qualified doctors to
refer patients to them – is laid squarely at the doors of these
self-styled doctors. According to Gurinder Singh Grewal, president of
the Punjab Medical Council, the state’s hepatitis C epidemic is down to
the unhygienic practices of ‘quacks’. “This is courtesy of the usage of
bad needles. Blood that is not tested is transfused to people in remote
areas,” he says. But others believe that training these rural
practitioners is the only way out of India’s healthcare woes.
Fifty-six-year-old Abhijit Chowdhury, professor of hepatology at
Kolkata’s Institute of Post Graduate Medical Education and Research and a
member of Liver Foundation, is one of the biggest champions of this
idea. Chowdhury insists that rural medical practitioners have delivered
essential healthcare to patients in remote parts of India, which
qualified doctors have abandoned in pursuit of high-paying urban jobs.
“On the other hand, there is this group of people, untrained and
unemployed before they got into this profession. But, in the dead of the
night, they are by the side of the people of the village when they are
in trouble.”
Since India’s independence in 1947, its government has tended to
overlook rural practitioners. They are illegal, but continue to exist
and thrive. State medical councils regularly organise drives to round up
‘quacks’ and file complaints against them. But the police rarely take
action, and the sheer numbers of these practitioners ensure they won’t
disappear anytime soon. Then there’s the biggest reason of all for their
continued survival – rural India doesn’t have enough doctors.
§
Picture this: you’re in Birbhum, rural India. You’re riding in a
toto, a three-wheeled, open-air auto rickshaw, the only mode of public
transport besides buses. Rattling past emerald rice fields, people
washing buffaloes in tiny ponds, and minstrels carrying all their
worldly possessions wrapped in little bundles of cloth, the toto rarely
exceeds 30 kph. Whenever it approaches one of the many treacherous
potholes on Birbhum’s roads, it almost slows to a stop.
Now imagine your toto is your ambulance. This is the journey that
many in Salbadra must make if they happen to feel ill enough to need a
doctor. Salbadra is a small village in western Birbhum, inhabited mainly
by members of the Santhal tribe, one of the largest indigenous tribes
in India. It doesn’t have a primary healthcare centre – the mid-level
government hospital with a qualified doctor that is the cornerstone of
the public medical system in India. The nearest such centre is 16 km
away in Mollarpur, and the nearest hospital that can admit patients is
35 km off in Rampurhat, approachable only by ill-maintained and potholed
roads. So, when they fall sick, the villagers of Salbadra consult
Aditya Bandopadhyay – the man who isn’t a doctor.
The World Health Organization specifies an ideal ratio of one doctor to every 1,000 people in low-income countries: India has one for every 1,700. It is even worse if you aren’t in a city, as only 20 per cent of them work in rural areas.
Rural India has a pyramidal network of government health centres:
sub-centres manned by assistant nurse practitioners at the base, primary
health centres with one or two general physicians in the middle, and
community health centres with four specialists at the top. According to 2015 numbers
from the health ministry, it needs one primary healthcare centre for
every 30,000 rural residents, but in reality 32,944 people have to share
each of them. In primary centres, 11.9 per cent of the doctor positions
are vacant. And at community health centres, a staggering 81.2 per cent
of specialist positions are not yet filled.
A few states, including West Bengal, have the lion’s share of these
vacancies. West Bengal has only 909 primary healthcare centres (against a
norm of 2,000 centres for its population of 90 million people).
Birbhum, one of the poorest districts of West Bengal, has 58 of them,
with 40 doctor vacancies. This means it has one primary healthcare
centre for around 60,000 people, a ratio that gets even worse in tribal
regions such as Murarai. And worryingly, at the bottom level of the
network, most sub-centres lack critical infrastructure, such as
electricity, toilets or water supply. “Doctors don’t like to stay in
rural stations,” says Himadri Kumar Ari, Birbhum’s chief medical and
health officer. “The facilities they have in Kolkata and other cities
are not there in rural areas.”
The final blow to India’s rural healthcare system is the rampant absenteeism among its doctors. A 2011 working paper
by a team of US-based researchers found that almost 40 per cent of
health workers were absent from their clinics on a typical day. While
the excuses they gave were varied, the absences were strongly linked to
poor infrastructure in hospitals and the economic status of the
districts where the hospitals were located. And doctors who faced long
commutes to impoverished areas were more likely to go AWOL.
This is the vacuum in government health infrastructure filled by the ‘quacks’.
§
Pramod Verma, a 35-year-old sales manager with a marketing firm in
Mumbai, approached his family homeopath with a fever in July 1992. The
homeopath, who had never been trained in modern medicine, prescribed
antibiotics for what he thought was viral fever as it was “very much
prevalent in the locality”. When the fever refused to abate, he gave
Verma antibiotics to treat typhoid fever, again believing this was
prevalent. Six days later, when the homeopath examined Verma again and
noticed a large drop in his blood pressure, he transferred him to the
care of a qualified modern medicine practitioner. But Verma’s condition
rapidly deteriorated, and by the tenth day of treatment he was dead.
This case, judged in 1996, marks one of the earliest Indian Supreme
Court judgements penalising rural practitioners. The judgement noted
that the homeopath had been negligent in practising modern medicine, in
which he had no training, and in not prescribing diagnostic tests to
determine the cause of Verma’s fever. “A person who does not have
knowledge of a particular System of Medicine but practices in that
System is a Quack and a mere pretender to medical knowledge or skill, or
to put it differently, a Charlatan,” the judgement noted.
But if you believe Abhijit Chowdhury, these practitioners have done as much good as harm.
He insists that Liver Foundation’s training programme is in keeping
with the Supreme Court verdict because it converts these self-proclaimed
doctors into a legitimate group of health workers. “If I can reduce the
negative attributes [of ‘quacks’] by 10 per cent and increase the
positive by 12 per cent, it is a net societal benefit.”
Chowdhury envisages a system of all rural healthcare practitioners in
an area enlisting with its district medical and health officer,
enabling the officer to take action during cases of malpractice. This
will make them more accountable, and visible to the regulatory system.
“Right now, everybody has closed their eyes to them. If this training
programme is given, they will become visible,” he says.
These practitioners remain the go-to people for medical care in rural
India, despite clear legal provisions and judicial precedents for
prosecuting them. And not just in rural areas – purveyors of ‘quackery’
boast thriving practices in poorer urban regions with an adequate public
health infrastructure. Meenakshi Gautham, a public health researcher at
the London School of Hygiene & Tropical Medicine, cites Tamil Nadu,
a southern Indian state with very few vacancies in its primary
healthcare centres. “But you still have rural medical practitioners. Why
is that? The obvious reason is that people’s health needs aren’t being
met.”
Even government hospitals with the resources to reach out to poor
patients aren’t as responsive as rural practitioners. Doctors in primary
healthcare centres call it a day by 14.00, but a ‘quack’ will still be
making house-calls in the small hours. Unlike short-term government
doctors, for whom village postings are a temporary nuisance, they are
available 24/7. And their client bases are smaller than those of
government doctors, who typically treat patients from villages spread
across large areas. This makes rural practitioners much more accountable
to their clients and, as they well know, more likely to be punished
when they screw up. “They are entrepreneurial workers in a
consumer-driven health market,” says Chowdhury. “They do not do bad
things consciously. They do bad things unconsciously.”
That’s why there are so many of them. It is also why they must be trained, argues Gautham.
§
Liver Foundation’s training programme in Birbhum takes place twice a
week. It draws around sixty rural medical practitioners from the various
corners of the district, and some from over the state border in
Jharkhand.
One such class is taking place on a hot August Sunday in a meeting
hall at the heart of Suri, Birbhum’s capital. A motley group of people,
mostly young, but with some grey heads among them, sit in the
high-ceilinged hall with fans spinning futilely above. They all wear
grey coats, their uniforms, and listen intently, pens poised over
notepads. The subject is tuberculosis, a major health problem in
Birbhum, and the teacher is Kajal Chatterji, a doctor at Suri’s
government district hospital. He is discussing the differential
diagnosis of tuberculosis, or how to tell if a patient with symptoms of
tuberculosis really has the disease or some other ailment that looks
like it. A chest X-ray can’t always diagnose tuberculosis, Chatterji is
saying, because tuberculosis-afflicted lungs can often look like
silicosis- or pneumonia-afflicted lungs in an X-ray image. Only a sputum
test can confirm the disease. The next bullet on his slide is about
tuberculosis of the lymph nodes. The laboratory diagnostic test for
this, Chatterji tells his students, is “fine aspersion cytology”.
After his final slide, Chatterji pauses. Sixty heads bow, and minutes
of complete silence go by as the students scribble on their notepads.
Suddenly one of them stands up. He has a question: where in the human
body are the lymph nodes located?
The message seems to be getting through. Students of Liver Foundation
have eager words of praise for their curriculum. Radha Binod Das, who
works in Shikaripara, a village in Jharkhand, says he does lots of
things differently after only a couple of months’ training. “I used to
give the wrong dose,” he laughs. “I used to give azithromycin 500 [an
antibiotic] two times a day for fever and cold. Now I give the medicine
according to body weight.”
§
In August 2015, the West Bengal government said it would consider
supporting Liver Foundation’s programme in order to help meet the rural
doctor shortfall. But the Indian Medical Association, one of the
programme’s most persistent critics, is set to contest it.
“These politicians don’t understand that modern medicine is practised
after six or six and a half years of training”, says Ram Dayal Dubey,
the president of the Indian Medical Association’s Kolkata branch. “How
can a person practise with two to three months of training?” Dubey is
scathing about what he sees as the legitimisation of a criminal
activity, comparing the programme to teaching burglars how to steal more
effectively. “They are doing illegal things,” he says of the
practitioners, “and Liver Foundation is training them to do illegal
things more scientifically.”
Opposition to healthcare providers without a proper medical degree
goes back a long way in India, particularly in West Bengal. During the
19th century, medical colleges produced two grades of doctors to meet
the exploding healthcare demand in pre-independence India. The first was
the fully-fledged doctor, after five years of education and training,
while the second was similar to Russian Feldshers – professionals
trained for three or four years who could handle acute and uncomplicated
diseases. They were called Licentiate Medical Practitioners, and by the
early 1940s they outnumbered doctors by a ratio of 1.7 to 1.
So in 1956, ignoring dissent from six of its members, the Bhore
Committee recommended a halt to the training of Licentiate Medical
Practitioners. This was taken up by the government of the newly
independent India and the Licentiate Medical Practitioner was eventually
abolished entirely in favour of a single grade of doctor – the idea
being that they would train so many new doctors that the country
wouldn’t need a lower grade professional.
Things didn’t really go to plan, as 2015’s rural health statistics
show. Yet the Indian Medical Association has repeatedly condemned the
mid-level practitioner idea. When the West Bengal government introduced a
three-year training programme for rural practitioners in the mid-1980s,
the Association mounted an attack. “We had several demonstrations and
rallies. Ultimately, because of the IMA's strong opposition, the
government had to stop it,” says Dubey.
In 2005, an Indian government task force recommended a new three-year
Bachelor of Science course for healthcare professionals to meet the
physician shortfall in rural areas. The plan was approved by the Indian
cabinet, but hasn’t yet been implemented by the Medical Council of
India, the country’s top medical regulatory body.
Chowdhury is exasperated. “The Indian Medical Association is a clan
of Brahmans,” he says, referring to the most elite caste in ancient
Indian society, who considered themselves intellectually and spiritually
superior to others. “They never listen to any argument, any reasoning,
any justification.”
The Indian Medical Association may continue its campaign against
rural practitioners, but others have bought into Chowdhury’s ideas. Not
least Jishnu Das, an economist at the World Bank, whom Chowdhury
approached in 2012 to help assess the impact of Liver Foundation’s
training. According to Das, Chowdhury, unusually, wants to use research
to understand the efficacy of his own programme, rather than merely
prove it to others. “I still remember him telling me that they wanted
the evaluation protocols firewalled from implementation, so that there
was no chance of contamination. He was very clear: ‘We don’t know
whether this programme is doing harm or good, and we need to know. Once
we have the results, we can see whether it’s an improvement or whether
we should just shut it down.’”
A 2015 study found that, contrary to popular belief, unqualified
doctors weren’t the sole source of unnecessary treatment. Das and his
team sent 22 patients coached to present symptoms of three diseases to
qualified and unqualified rural doctors. The team then graded their
abilities to accurately diagnose and treat the diseases. They found, not
surprisingly, that qualified doctors provided correct treatment about
30.9 percentage points more often than unqualified ones. But there was a
bombshell: qualified doctors were 26.7 points more likely than
unqualified providers to prescribe needless antibiotics to patients.
Unqualified doctors indulged in overtreatment too (several other studies
confirmed that over-prescription was indeed a big problem among rural
practitioners), but the unnecessary medicines they prescribed were
typically over-the-counter drugs such as vitamins. During interviews,
Das says, the rural practitioners seemed wary of prescribing strong
antibiotics, whereas qualified doctors showed lesser caution.
It is the overtreatment by qualified doctors that Indian medical
councils should crack down on, says Das. They are, after all,
responsible for regulating them. “Instead of doing that, which they know
is very hard, the thing seems to be to construct a narrative that
informal practitioners are creating all the problems. No, the informal
practitioners are not creating all the problems. They are there because
there is no option.”
There is growing evidence from other low-income countries with
unqualified medical practitioners, such as Uganda, Peru and Bangladesh,
that training can greatly boost their competence. In 1983, a study
carried out in Valle Del Cauca, a state in Colombia, found that over 70
per cent of surgeries in rural regions could be handled by health
workers with less than six months’ training. These included hernia
repairs, circumcisions and caesarean deliveries. More recently, a 2013
review of research on informal providers found that 14 out of 16 studies
on the impact of training reported positive outcomes. The providers
tested in the studies included midwives, general practitioners, and
pharmacists who dispensed prescription drugs to their customers for
sexually transmitted diseases. Apart from two studies, which saw mixed
outcomes, training helped them to give better care to their patients.
Choppari Shankar Mudiraj, a rural medical practitioner of 30
years and the head of an association of others like him, effusively
praises the decision. “This is a revolutionary change. It is the first
time such a thing is happening in India. Across the world, there is only
one other country that has a concept such as barefoot doctors. That is
China,” he says, referring to a 50-year-long phenomenon in China in
which peasants trained in basic medicine later became vital to public
healthcare in the mid-20th century. They focused on preventive
healthcare, such as immunisation and sanitation, but many eventually
studied to become qualified doctors. China’s success in reducing
infectious diseases such as polio is partly down to these peasants, who
would dispense medicine from village to village.
Mudiraj believes the Telangana training programme will equip him to
provide high-quality medical care to his patients, just as China’s
barefoot doctors did. Ordinary people find it hard to go to hospitals,
he says. “We leave the villages where our families are and go to the
remotest, hilliest of areas. We have treated people who have been bitten
by snakes and attacked by bears. We go to their houses and treat them
because they can’t come to us.”
For Mudiraj and his colleagues, treating patients comes before any
monetary gain. This is why they are happy to accept small amounts of
food grains or vegetables as a fee, if the patient has nothing else to
give. “There are times when I have given service for two rotis,” says Choleti Balabrahmachari, a rural practitioner from the Nalgonda district of Telangana. “When he doesn’t have two rotis, I forgo even that.”
They say they have contributed greatly to the country’s public health
programmes too. When the Pulse Polio infant immunisation scheme was
launched in 1995, district collectors asked influential rural
practitioners for their help. “They said, ‘We will send our sisters
[nurses] to you’,” says S Venkat Reddy, the president of another
association of rural practitioners. “These sisters don’t know the people
in villages like we do. They don’t know which households have small
kids, but we do, because we go there.”
Reddy says he and his colleagues ensured that countless children
received vaccines, driving India’s success in eradicating polio. Many
vaccination camps were located next to rural practitioner clinics, to
reach as many people as possible. Rural practitioners have also
participated in family planning, tuberculosis control and AIDS awareness
programmes over the years.
This kind of influence means they also enjoy much political
patronage. According to K V Narayana, a health economics researcher at
Hyderabad’s Centre for Economic and Social Studies, village leaders
support rural medical practitioners because they receive free treatment
from them. This makes them influential in shaping public opinion. “[The
rural medical practitioner training course] basically started as a
populist policy. Because they matter a lot in rural areas to political
parties,” he says.
But this motive rankles several doctors, who think the rural
healthcare system has suffered terrible neglect. They believe doctors
avoid rural areas because the government has done precious little to
keep them there. The infrastructure in primary centres is bad, they say;
the recruitment process is long-winded; salaries are poor, and medical
interns are not even recognised as genuine doctors. Last but far from
least, government monitoring of absenteeism in village hospitals is
sparse.
Shyam Sunder Kasapa, the Telangana branch president of the Indian
Medical Association, says everyone – doctors and the government included
– should reflect on this. Turning to rural practitioners instead of
fixing the huge problems in India’s healthcare system is just a
political gimmick, he says. “The government’s idea itself is
discriminatory,” he argues. “So paramedics can treat rural people, but
you need specialists and super specialists for [urban residents]. Is it
justified? Don’t [rural people] have equal rights?”
Good question. Gautham envisages a two-phase strategy: training the
rural practitioners to address the immediate gap in healthcare, while
also training more doctors so that gradually the need for the
practitioners decreases. “The long-term strategy cannot be to keep
training informal healthcare providers. This market cannot remain
informal forever,” she says. But she insists that some kind of mid-level
practitioner must be trained. That is something both the Medical
Council of India and the Indian Medical Association stubbornly resist.
These disagreements do not bother Chowdhury. When rural health
practitioners like Aditya Bandopadhyay graduate from Liver Foundation’s
programme, the medical councils will have no power over them – as long
as they don’t call themselves doctors.
Chowdhury will plough on: creating doctors is not his priority. The
system doesn’t produce medical professionals who can solve the problems
of rural India, he says; it rewards specialists who treat the diseases
of the minority. “I wish for thousands of villages to have health
workers who are capable of taking care of fever, malaria, and
identifying high-risk mothers and sick children to be referred to a
health centre with trained doctors.” He doesn’t need the regulators’
approval for that.
******
No comments:
Post a Comment