PERSPECTIVE
"Kal, Aaj aur Kal of Health Manpower!"
Ajay Kalra
The Past
Nearly four decades back, I had the privilege of being a co-author of a paper on raising a manpower for healthcare in villages with my teachers and mentors, the most venerable Late Professor R.S. Dayal Sir and Professor (Madam) Kanwal Kalra (“Raising an Auxiliary Force for Medical Care in villages"[1]). What we had stated at that time was as follows:-
"Over three decades of independence of our country have witnessed tremendous development in the agricultural and industrial fields. On the medical horizon, too, we have scored some achievements......................However, these achievements are of lesser significance considering the nature and magnitude of the problem. A truer index of our achievements in the sphere of health is the success of the medical services as they exist for the rural population. The present set up of health services has been inadequate in that respect. Partly, the reason for this can be traced to our system of medical education. This system although academically strong, remained socially ineffective, for educational quality has to be judged by the success with which it meets the needs and not by the competence with which its graduates satisfy an ill-defined international standard of excellence"......................"More important, however, is the fact that most of the doctors still prefer to work in cities. While rural : urban population is in the ratio 8:2, the concentration of the doctors is just the reverse, being 1 in rural areas for 10 in urban; the doctor : population ratio being 1:11,000 in rural areas and 1:1200 in cities."
We had then ventured to make the following recommendations :
"We, therefore, recommend creation of a new cadre of practitioners, similar to the licentiates of older times who, it is felt, may be able to deliver the goods within, say, 15 – 20 years."
The suggested criteria of selection was : "They should have been permanent residents of rural areas.......................They should have maximum basic education of 12 years and attained the age of 17 years."
And further, "The total period of training can be 3 years divided into six semesters"......................"they would be licensed to practice or serve only in the rural areas" and "their license, not being internationally recognized, they would not be able to migrate to other countries".
While emphasizing this as a time bound, stop gap measure for 15 – 20 years only, we had discussed the career prospects of these licentitates starting from Junior Medical Licentiate to finally the Chief Medical Licentiate through stages of Medical Licentiate and Senior Medical Licentiate. We had also cautioned to add that"such a suggestion should not, by any stretch of imagination, be construed to imply that villagers are to be treated as second class citizens destined to receive a second-rate assistance. It is an honest attempt to provide some scientifically valid care where none exists."......................."Let us hope that even under strong political pressure, our government will not be obliged for upgrading these licentiates to physicians, as had happened in some countries (Ethiopia and Iran)."
The Present
Now, nearly four decades later, the same concern of shortage of health care personnel seems to prevail. It has been taken up by Dr. Vipin Vashishtha in his lead article in the last issue of Pediascene (“Don’t convert doctor into an endangered species!"[2]). The similarity between the past and the present is striking :
"The doctor to patient ratio in India is only six for every 10,000 people or one doctor for 1,700 people compared to the WHO norm of 1:1000. Most of these doctors are in urban areas, while close to 70% Indians live in rural provinces......................The global ratio stands at 15 doctors for every 10,000 people."
"As described above, there is extreme shortage of doctors particularly in the remote rural areas. There are instances where a pharmacist is seen performing surgery and sweeper is dispensing medicines at a public health picket. At most interior places, quacks are the first point of contact for the most rural folks during the time of emergency. So the immediate need of the hour is to train these delivery points in the basic health care course of short duration till we have adequate trained doctors to man these interior health centers....................... The existing delivery points including quacks should be brought in to the fold by imparting basic training courses in emergency healthcare. ......................the scarcity of MBBS doctors in the country should be another top priority for the government. Efforts should be made to double the UG and PG seats. The existing district hospitals at every district headquarter should be upgraded and converted in to a medical college."
And further,..."Till adequate doctors are available, other innovative options like creating cadres of ‘rural doctors’, training of Ayush doctors in delivering basic minimal healthcare, limited privatization of rural healthcare delivery etc can be thought of."
Thus, it is obvious that even today the country continues to grapple with the issue of shortage of health care personnel. Hence, in the last few years, there have been concentrated efforts to address this problem by :-
- Increasing the seats of medical graduates and post graduates.
- Making new medical colleges and institutes
- Raising or integrating an alternative cadre to meet the shortage of doctors.
In the 1980s, we had recommended a cadre of licentiates. Now, presently the government is working on the training of Ayush doctors in modern medicines as an innovative measure to raise a cadre of neo-doctorsto meet the requirements.
The medical profession, represented by the Indian Medical Association, seems to be up in arms against this move. As in 1980s’ I still think it is imperative to have such an alternative cadre to tide over the present shortage of doctors. Many of the third world countries who were far behind us in health indices, have done much better than us by training and licensing even the paramedical staff in primary health care delivery.
However, this does not necessarily mean opening new medical colleges, because the costs are astronomic and it opens the gates of corruption, besides using dubious means of fulfilling the requirements of faculty. A better way seems to be to go for Capacity Building of existing medical colleges to double or treble the graduates and post graduates from these colleges. The district hospitals and other big hospitals can also be geared up to train the alternative cadre of Ayushs etc.
The Future – Artificial Intelligence! Yet another cadre of health personnel?
The medical fraternity is unduly worried about itself. Notwithstanding our reservations, as the health scenario moves from disease centric to emphasis on wellness, the Ayushs and Yogashrees will be the most sought after health personnel in the country. We should also realize that in the very near future, Artificial Intelligence (AI) will either replace most health personnel as they are today or change the whole spectrum of jobs in this field.
We have moved from typewriters to computers to smart phones. Instead of traditional taxi hiring, we order OLA and Uber cabs using AI. We are into online shopping and delivery of food at our doorstep. We are in an era of driverless trains and cars as much as we have automated air flights. All these are examples of Artificial Intelligence. In the medical field, AI has already started making its impact. Diagnosis of illness is getting fast, efficient and highly personalized. New drugs are expected to come to the market faster and clinical trials are becoming more accurate. It is already being used in detecting skin cancer, diabetic retinopathy and macular degeneration, new drug development, reading CT scans and recognizing depression. Researchers in China have shown how a robot which had absorbed the contents of dozens of medical textbooks, millions of medical records and articles, passed a medical license exam test in a fraction of time of its human peers with better accuracy[3].
The days are not far when a person in any corner of the world will be diagnosed and treated by an engineer or a technician trained through AI in dealing with medical problems, or even by an enlightened family member. The dice has been laid. The Niti Ayog and the government have made a strong beginning in this matter[4]. Only, if we would wake up and try to know about this, rather than devoting our time and energy in fighting over narrow issues of which group or caste or category, we belong to and the privileges we ought to have.
The vast diversity of data that this country is capable of generating through AI in the medical field, will give us an edge and an opportunity to be the world leaders in medical education and health care.
REFERENCES:
[1] Dayal RS, Kalra Ajay, Kalra K. Raising an Auxillary Force for Medical Care in Villages. The Indian Journal of Medical Education-20(2), 1-4, 1981.
[2] Vashishtha VM. Don’t Convert Doctor into an Endangered Species. Pediascene-18(1,2),3-6,2017
[3] Gray Alex. 7 amazing ways artificial intelligence is used in healthcare. https://www.weforum.org/agenda/2018/09/7-amazing-ways-artificial-intelligence-is-used-in-healthcare/ Accessed on 16-12-2018
[4] Artificial Intelligence – How does it help India : New Sankalp India/ Part 94. https://youtu.be/h8Q9yhBKSlo . Accessed on 16-12-2018