BSc (COMMUNITY HEALTH): PANACEA FOR RURAL HEALTH?

I came across an article by Dr Neeraj Nagpal ,(Convenor, Medicos Legal Action Group
Ex-President, IMA Chandigarh) on BSc Community Health.

I found it very thought provoking and informative, so sharing it in this page for you.

Dr Neeraj Nagpal

There is no dispute on the fact that rural healthcare in India is abysmal and drastic steps are needed to rectify the same. There is also no doubt that this involves a multipronged approach. A community health worker (Anganwadi worker, multipurpose health worker), a nurse practitioner, a pharmacist and a doctor available along with the infrastructure, medicine supply with improved connectivity (roads), electricity, safe water supply are all prerequisites to improved rural healthcare.

At different times in different states different schemes have been launched whereby the community health workers named differently in different states form the first line of community healthcare. Never however has an attempt been made to replace a doctor with a community health worker as is being done now under the garb of BSc (Community Health).

The fact of the matter being that though on paper we have rural dispensaries in every nook and corner of the state they fail to provide healthcare to our rural populace. The reasons are not far to seek. The buildings are in shambles with no resemblance of a hygienic healthcare facility as required under the Clinical Establishments Act. Rickety chairs and tables serve as infrastructure and even these are missing or broken. Electricity is mostly not available due to power cuts. There are no facilities of generator (how vaccination programmes are run without the cold chain is shrouded in mystery). Without proper autoclaving no procedures or surgeries are feasible in these dispensaries. Water supply even in dispensaries is from a hand pump if at all. Few of the dispensaries are approachable only by horse drawn vehicles, as buses do not travel to them.

Given the futile exercise of marking attendance in such dispensaries it is surprising that employees whether doctors, nurses or pharmacists come to work at all. This is a vicious cycle. Patients stop coming to these dispensaries as on previous visits their need at the time was not fulfilled whether because the doctor was absent, or medicines not available, or the procedure could not be done due to power cut etc. They then approach quacks, who thrive in this environment, for their daily medical needs. Also, disease does not seek to afflict a person only during office hours. To tackle patients in off duty hours appropriate residential arrangements for staff are sorely lacking.

In the Supreme Court, shortage of doctors in the country has been touted as a major problem. Government has shown statistics that India has 1 doctor for 1700 population. What has been glossed over in these statistics is that this figure is taken from the Medical Council of India (MCI), which concerns only with MBBS doctors. Are the doctors from the alternate system of medicine not doctors? BAMS (Bachelor of Ayurveda, Medicine and Surgery), BHMS (Bachelor of Homoeopathic Medicine and Surgery) and BUMS (Bachelor of Unani Medicine and Surgery) graduates all have four-and-half-years study of their systems of medicine including basic subjects like anatomy and physiology. Their number is any day more than that of MBBS doctors. If we include them in the statistics the ratio of doctor to patient in the country will be much less than 1 per 1000 recommended by the World Health Organization (WHO).

Either we consider them doctors or we do not consider them doctors for the statistical purposes. Even these doctors with 4-5 years of graduate study are labelled as quacks by the honourable Supreme Court if they dabble in modern medicine (Poonam Verma vs Dr Ashwin Patel). How then can a truncated study duration of 3 years equip someone with knowledge sufficient to practice modern medicine.

There is also the fact that for government health services in nearly all states there are many more MBBS applicants than seats available. All doctors in Government service have to do mandatory 3-5 years rural service as per different state norms. Punjab Govt managed to rope in about 1200 MBBS doctors to serve in rural areas on adhoc basis on consolidated salary of Rs 30,000 out of which they were also supposed to pay salary of two employees. These doctors were not given any service benefits and were appointed under the Zila Parishads. “Shortage of doctors” or that “MBBS doctors do not work in villages” is then a myth created by the powers that be to further their own ends. With unemployment and underemployment existent among MBBS doctors where is the need for a special cadre of rural doctors?

The reason why the political class is keen on BSc (Community Health) and of permitting them to practice modern medicine is to be seen in a different context.
Medical education has shifted from government medical colleges to private medical colleges in large numbers. Most private medical colleges are run by politicians or their relatives and henchmen. Lot of money is involved in medical education with an MD seat being sold for Rs 2 crore; even BSc (Nursing) and BAMS courses are fetching good premiums for these colleges. This puts a lot of pressure on the management of these colleges (politicians) to get more seats and medical colleges approved from the MCI. Resistance to the same has cost the MCI dearly. It has been disbanded; adhocism prevails in appointment and removal of the Board of Governors. The entire sequence bears a close scrutiny by an independent agency preferably the Central Bureau of Investigation (CBI).
If one (MCI) member Dr Ketan Desai was corrupt (not convicted) how does it justify the dissolution of an autonomous body with elected members? By the same argument the corruption of Mr Raja and Mr Kalmadi should lead to the dissolution of the parliament.

BSc (Community Health) is simply another way of selling medical seats without interference by the MCI. This would be possible only if the powers that be are able to get some legal sanctity to the BSc CH graduates practicing modern medicine. It was rightly pointed out by professional medical associations and legal luminaries that involvement of the MCI will need changes to be made in the Indian Medical Council Act. Govt has now cornered the National Board of Examination (NBE), a body which so far concerned with governing postgraduate medical courses Diplomate of National Board (recognized postgraduate teaching qualification even in medical colleges), to now award alternate of MBBS i.e. BSc (Community Health) degree.

Doing something new which would be marketable even if it were recycled goods has been the cornerstone of political gimmicks perpetrated in our country by our esteemed lawmakers. General elections being near there is a political compulsion for the government to have in its agenda schemes, which can be touted to voters as accomplishments. That it maybe illegal or harmful for the nation’s health is inconsequential to this breed of politicians and they are willing to tweak the law to meet their desired goals.

There is no magic wand to improve healthcare in rural areas. Posting a doctor in a rural dispensary of today with his hands tied for want of infrastructure, medicines and equipment is akin to hanging a photograph of a doctor in the dispensary. It serves no purpose except on paper. Because qualified doctors are demanding these facilities it is now prudent to replace them with hopefully a more pliable army of qualified quacks in the form of BSc (Community Health) graduates (Rural Doctors). Plus there is money to be made in starting these new courses for rural doctors.

Dr Neeraj Nagpal
Convenor, Medicos Legal Action Group
Ex-President, IMA Chandigarh                                             

SOME EPIDEMIOLOGICAL TERMS

Incidence is a number equal to the fraction of population that contracts a given disease during a given period of time. In other words, Incidence is the rate at which new cases of diseases occur within a population.

Prevalence of a disease is the fraction of the population that currently (or at some other particular time) has a given disease.

A sporadic disease is one that occurs only occasionally in a population (i.e., prevalence is zero).

An endemic disease is one that is always present in a population (i.e., never zero prevalence).

An epidemic disease is a disease that many people acquire over a short period (i.e., increasing incidence).

A pandemic disease is a world-wide epidemic disease (i.e., high world-wide incidence).

Common source outbreaks are some diseases arise from a single definable source, such as a common water supply. They are not propagated from individual-to-individual (e.g., person-to-person). Yet the disease continues to be endemic and perhaps epidemic as a consequence of contact with some typically geographically well-defined disease reservoir

Propagated epidemics are in contract, which are diseases spread not from some common, geographically well defined disease reservoir, but instead by individual-to-individual (e.g., person-to-person) contact.