Tuesday, April 17, 2007

Doctors for villages?

Why is nobody making any noise over this?

If you don't have the patience to read through the article, what the Government is proposing is this:

... for all new MBBS graduates to serve in a rural area for one year as a
precondition for being granted permanent registration...


It's the perfect socialist scheme. Government abdicates responsibility, puts clueless, young people on the spot by entrusting nation-building in their inexperienced hands and watches the fun while people squirm in their seats. It's a scam because our villages deserve better. It's a scam because our medical graduates deserve better than being asked to sweat their asses off, trying to clean up the Government's mess.

Here's why I think this is wrong -

1. It violates individual freedom and choice. Why should this be made compulsory? Does that not say something of its own? Why should social service be obligatory? People become doctors for their own reasons, some to save the world, some to make money. Why should the government assume that it has the right to tell doctors where to work? What next? Engineers being asked to compulsorily intern for a year, building generators and setting up communication networks in villages before they can graduate? If that's the case, why not bring in a minimum period of social service for politicians before they can contest elections? All I'm saying is leave it to the individual. He or she knows best. Starry-eyed idealism should not be forced down people's throats.

2. Why should the government have to introduce this scheme in the first place? Sixty years of fiddling around with the health-care system means (as the article says) "up to 40 per cent of the doctors posted in primary and community health centres fail to turn up". That's almost one in two. I wonder what happens when they do turn up. Maybe the patients are dead by then. Why doesn't the Government learn? It's simple labour economics. Make it worth their while. Invest money where it is needed. Establish a better network of clinics/hospitals with better equipment, hold the doctors and other paramedical staff responsible, bring accountability into the system. But no, they won't do that, they will continue to rob Peter to pay Paul, they will continue to squabble about Greg Chappell in parliament and wait for the next elections to come around. We so have our priorities in place.

3. Read this for more. You can see the situation already. Rookie doctors saddled with non-existent equipment, scratching their heads when required to make a speedy diagnosis. It's like taking someone from the junior Cricket leagues and dumping him right into the pressure-cooker scenario of a Test match. I'm not saying our medical graduates are dumb. Just that from a working knowledge of the present educational system, I'm very sceptical about their abilities to provide quality medical assistance, especially with zero experience. If anything, our villages need better doctors than our cities.

4. If you look at it from a corporate angle, our villages being customers would end up at the receiving end of very poor service. Why should they accept this scheme? Because the system is in such a sorry state they will be happy to get anything that comes their way, instead of rapping the government on the knuckles for suggesting this hare-brained scheme.

5. Why are the doctors and the medical associations keeping quiet? Why aren't they protesting? Where are all those placards and those marches? Because the medical profession is a "noble profession" and because if they say anything, they will be labelled "selfish". Damned if you do. Damned if you don't.
6. In fact the Government deserves more credit than we give it. Staffing community clinics with quality doctors and then retaining them will mean higher health-care costs and hence they can't swindle as much as they are swindling right now. So what do they do? Ensure an annual supply of low-cost personnel, who a) won't have the inclination to hold themselves accountable and b) will purely be looking forward to the end of their tenure so that they can get on with furthering their career aspirations. Brilliant solution for eliminating any worries about attrition.
7. And why is The Hindu sucking up to this scheme by calling it "commendable"? Later on in the article, there is a mention about the real problems, which are, to admit, quite obvious. So why isn't this scheme being judged in the face of these serious issues? But no, it talks about "systems in place for the graduates who are thus posted, not only to widen but also sharpen their knowledge and skillset through programmes for professional enhancement and continuing medical education." But of course! The Government would be very keen to do that now, won't it? I used to wonder why people called The Hindu "Leftist". I understand fully now. As a so-called "responsible newspaper" why is it not taking the opportunity to slam the government for taking the easy way out? Cop-out, if you ask me. Both government and media.
And then people ask me why I don't read newspapers.
Ignorance is bliss.
Update -
I'm posting my arguments on some positions as an update. Counter arguments can be posted on blogs and a link left in the comments here, or can be emailed (find email id on my profile page).
  1. The subsidy argument - "Government subsidizes medical education, so it has the right to force Doctors into one year of service in the rural areas". Assuming that a subsidy gives the Government the right to force the one-year stint, the radical free market stance would be to ask for zero subsidies and indulge in "richest will survive" rhetoric. Since that is not practical (India having a lot of poor people), I'm suggesting three things - a) Give a loan to cover the existing subsidy, b) Give students the chance to decide whether they want their education to be subsidized or not. That way, students who choose the subsidized education also agree to serve the one-year term, c) Provide the subsidy based on economic status, so that the students from the lower income groups get cheaper education and also serve the one-year stint.
  2. The one-year term is an additional subject/ It is just like an internship - I have problems with this on many fronts. First, the motive. That such an internship will provide valuable education is a baseless and flawed assumption. Is there any concrete evidence for this? Has a study been conducted by any medical education board to say such a stint will add value? No. On the other hand, given the existing facilities and the current educational scenario (as evidenced by the article from The Telegraph), it won't be wrong to say that any education that such a stint might provide would be of lesser value than one pursued by a doctor on his/ her own. So, there is no evidence to suggest that this stint will be a good "subject" to add to the syllabus and moreover, the Government does not have the authority to unilaterally add such a "subject". The motive is not one of education and learning, but to somehow tide over a problem, caused by the ineffectiveness of the Government, with cheap labour. Second, internships are again choice-based. The student decides where to do the internship. He/ She has the freedom to make that choice. As far as I know, no institute demands that internships should be done only at a place of their choice. Third, assuming that it is a valid additional subject and that it is just an internship and that it's good training, why make it compulsory? Why not make it optional? Fourth, the proposal (thus far) is for the freshers to work, with very little guidance. How can one call this a "subject" or an "internship"? Again, this argument simply doesn't make sense.
  3. Lassitude/ shirking responsibility - In a democracy, one has the right to employment, consequently the right to voluntary unemployment, and education. It is morally wrong, in a democratic public domain, to deny someone education, and hence discriminate against them, just because he/ she doesn't want to work. If a doctor doesn't want to treat a patient, it is still his/ her individual choice, one with negative consequences. You simply can't deny him/ her that right. You can't force them to treat patients. I will defend their right to not treat a patient but I will condemn their actions and insist that they pay the necessary penalty. That's the whole point of liberalism! And what is this about shirking responsibility? If at all anybody is shirking responsibility, it is the government! You elect a government, pay taxes to keep it running (which includes providing health-care to the rural areas) but you find it is not doing its job properly. So what do you do? You don't pull up the people concerned, you don't take them to task, you don't file RTI applications to find out where the money went, you don't ask why doctors don't turn up for work, you don't ask why facilities -- for which money was sanctioned -- are non-existent. You don't realize that the price of freedom is eternal vigilance. No sir, you won't do that. What will you do? Suggest that stringent measures be introduced for certain professions, including forcing unwilling doctors to serve a year in god-forsaken places. Brilliant. Heck, why have a government in place at all! Might as well run the country ourselves. In my opinion, the well-to-do citizens of this country are being sent on a guilt trip. People find they are doing well in life because of their own efforts but are being made to feel guilty about not doing enough for the country (what with movies like RDB). And what do they do? Instead of being active citizens participating in governance and making use of the RTI Act (which in my limited experience of working with it has yielded amazing results), they support such schemes. Why? Because, hey, participative governance and the RTI Act are just too much work and not as cool as asking doctors to sacrifice a year of their lives. Why be intelligent with my actions when I can be stupid with my sacrifices? Might as well support this scheme, go easy on individual rights and feel I'm patriotic. My stance is this: the citizens should focus on repairing the existing system, which can work provided the bureaucratic hassles and corruption are removed. We need to make sure that all has been done and the system is still not working before going around begging for people to spare some time for their country. Even then, it will have to be of their choice.
  4. This is an experiment and can be judged only after it's been tried out - If the motive is just to see if it works, why make it compulsory? Make it optional. I'm sure there will be certain service-minded doctors who would want to give it a try. We can still judge the concept by keeping it optional. I don't see the logical connection between judging this scheme as an experiment and making it compulsory.
  5. We are disgruntled anyway/ Choice and freedom are mirages - (Personally, being a participant in an almost free-market, my actions have been directed towards optimizing my happiness, and I'm happy with where I am) Even if choice is a mirage, I make that decision to consider choice a mirage. I choose to believe in that. Someone else can't tell me "hey, choice is an illusion, so you might as well come and work for me for minimum wage". And even if people are disgruntled, they have the right to choose to be disgruntled. Nobody else can force them into a choice they are disgruntled with.
  6. A couple of instances of strawman fallacies about how I'm advocating privatization of the health-care system make me reiterate my stance: I'm NOT asking for privatization of health-care. I'm purely asking for the Government to own up to its failure, clean up its act and restore the system to what it should have been in the first place.

37 comments:

M (tread softly upon) said...

Excellent points. Why do more doctors not voluntarily go serve the rural communities? Poorly equipped facilities and understaffed communities, true. But what is more scary is the politics and bureaucracy that plays a pivotal role in these rural areas. I know of doctors who get "dead" patients brought to the health center in the middle of the night with a demand for a death certificate. And of course you are not allowed to refuse or question the cause of death and most definitely no post mortem. When the doctor refused they threatened to kill him. The result? The doctor fled through a bathroom window and took the next train out of there. And you still think anyone would choose to serve voluntarily? Not me.

dazedandconfused said...

I disagree with you. I think it's a good idea and if I were a medical student I would welcome the opportunity.

1)Yes, in a way it does violate individual freedom of choice but since most of our medical institutes are heavily subsidised, I don't think its unfair to ask their the doctors to give something back.

2) We are a poor country. Labor economics- "making it worthwhle" for doctors is a armchair notion. The rest is a rant.

3) You are right there but I guess the main problem is getting somebody in the first place. It would actually be better then, to suggest that every practising doctor should spend his say, 6th year of practice in a rural area or else his registration gets cancelled.But that would be more unfair on the doctors than the proposed system...If they had to give a year, I figure most doctors would prefer to finsh it off early in their careers...

4. I think the villagers will be better off than the current system where there is nobody to go to.

5. You are right. Though I don't agree that they would be damned if they do. It might be the best and most uplifting experience of their lives and not just in the medical sense.

6. Maybe a few doctors might want to stay on there. Who knows...

7. The perfect solution is a mirage. It doesn't exist. Anything which may improve things even incrementally- I say go for it!

Ignorance is not bliss. That's a cop-out.

sudeepchat@yahoo.co.in said...

All well said. However,
1.who is the government?
2.And leaving everything to economics does not make a fine situation as you assume - US, France, etc prove this fact with the state of their health system.
3.Ask not what your country does for you but what you can do to your country. Does this ring a bell?
4.Finally, for someone like me who has chosen to work as a doctor in rural areas, your criticism comes across as armchair rage.
-Sudeepto Chatterjee

zeya said...

I also think its "remarkable step from government". We as citizens have become so selfish and narrow that we need such enforcements to do what our conscious would have told us to do..
If a country's citizen dont do their bit of social work themselves. There's no harm in proposing it by force on those elite class. Who are supposed to know it by themselves. I know all the pitfall indian govt has. But are n't we the one, who have also allowed this to coninue. Frankly speaking as an electrical engr i would have loved if we were asked to build power distribution scheme for some remote village in our third year, than listen those ineffective professors telling how power systems works. I would really appluad if something like that also becomes mandatory..

Freedom said...

Serving one's country is definitely a noble cause. HOWEVER, if this is implemented by force it is pure evil. An individual's right to decide his(her) own future is far more sacred than "serving" in rural areas. Now I know why the NRA and the right wingers in America are so paranoid about individual rights, if a little space is given to the collectivists/socialists they start infesting like parasites.

Anonymous said...

Musafir, I kind of agree with you when you say the government is suppressing individual freedom by forcing new grads to work in rural areas. However, if it is able to provide the supporting infrastructure, guidance (by means of perhaps a senior doctor) etc, then this scheme might actually benefit the new grads. And, so it might be actually good.

As for govt fiddling with the medical system, this is kind of the result of the apathy of the doctors to rural india to an extent, And the fact that it was a point in the CMP.

I mostly agree with what you say there, but then as usual not the whole way. :)
Sudip above - i appreciate the fact that you do serve in rural areas. but, as you very well might agree, villages need more medical facilities than probably urban area and as a new grad, to be able to identify these issues and overcome them might be asking a bit too much. I might be shooting the dark here, but did you choose to serve in the villages right after your MBBS..? My answer/guess would be no.

Dazed and confused - i wanted to just comment on one of your points. The "make it worthwhile for doctors" - the govt has not, till now, made it clear how it is going to implement the scheme - all it says it is mandatory that new mbbs guys go serve in the rural areas. how is it going to ensure that it is being done ... unless clear proposals emerge as to how this is going to be enforced, then the only way i can see of the doctors actually attending to their jobs is if it is made worthwhile for them. so, it is not all an armchair notion. I rmeember one post in India uncut where amit talked about wildlife preservation. i would kind of say to apply the same solution in this case also, it would only make the scheme more efetive.

For me, I would still think it is too early to commend or criticize the scheme, unless the guidelines are laid out.

Vi said...

Agreed. It sounds a tad Maoist.

Anonymous said...

u have let ur emotions write for u for the first time i suppose. did u know that CMC has always had this policy and yet every yr we have 1000's vying for just a few seats? this seems like an intellectual outrage/"armchair"! neways u seem to have caused quite the stir!!!

Randhir said...

There is no point in flaunting my own credibility on this subject, but you, my friend, dont seem to have any direct or indirect exposure to rural healthcare, and what its needs are.

I appreciate you spending the time to write this, and the interest it has generated, but most of your observations are impulsive, shallow and baseless.

musafir said...

m (tread softly upon)

That is something the Government and people who call for voluntary social service should think about. Why don't people want to serve voluntarily? There are a lot of people out there who would have no qualms about serving the community, but at what cost? One IIM graduate and an IIT Engineer decide to question malpractices in the system and we all know what happened. People should be aware of ground realities before they call for the youth to stand up and serve.

dazed and confused

Disagreements are welcome.

1. The subsidy issue. I was going to update the post with my thoughts on that today, but then since you've raised it, one has thoughts at two levels -

a) Assuming it's fair to ask the doctors to give back something - Give students the option when they get admitted. Either the Government subsidizes your education wherein you serve in the rural areas compulsorily for one year after you pass out, or the Government doesn't subsidized your education and you're free to do what you want after you graduate. That shouldn't be too difficult to implement, I guess. And I'm assuming that the Government will bring this into force only in the Government-aided colleges and not in the private ones.

b) The moral right of the government to ask people to give back to the country - How different is this from conscription and the draft? Wikipedia gave me this from the Anti-conscription manifesto - "The State which thinks itself entitled to force its citizens to go to war will never pay proper regard to the value and happiness of their lives in peace." It is not too much of a leap to extend the argument to this scheme. In my opinion, I think the Government should provide education with no strings attached. And this is without getting into the debate about the Government's role in education. If by providing subsidy, the Government can demand anything, then why not go ahead and ask the doctors to work all their lives in the places where the Government wants them to? What's with the one-year deal? And why just stop with the subsidies on education? Why not expect something in return from all the areas that the Government subsidizes? Subsidies should be looked at from all angles.

My stand is this - The Government should do all that it can, let it put the tax-payer's money to good use, let it clean up the system and if we are still faced with a health-care problem, then a similar scheme, less draconian and individual-friendly can be thought of. The Government is simply not doing its job well. If it did, we wouldn't need schemes like this. Putting the country ahead of the individual is sure to cause unhappiness.

Sacrfifices are noble, yes, but then they shouldn't be stupid.

2) Not sure what your definition of poor is, but accepting that for the moment, does that justify the pathetic state of affairs of the health-care system? And the corruption that is rife? I'm sure there are countries "poorer" than ours, and less corrupt, who manage their health-care systems without having to resort to such schemes. And why is labour economics an armchair notion? And why does it being an armchair notion detract from the validity of its argument? I don't see the connection there.

3. It's very difficult to believe in the effectivesness of anything that's not done voluntarily. 6th or 16 the year. Have to disagree with you on that.

4. Yes, agree.

5. I meant, damned if they do protest, damned if they don't protest. And "best" and "uplifting" are subjective issues, and are not worth arguing about.

6. Maybe.

7. An incremental increase in the effectiveness of the system at any cost? Of course, as long as the happiness of a few are sacrificed for the greater common good! The end does not justify the means (the Narmada Valley debate all over again). Why is the Government lazy and unimaginative? Why is this the only way out?

sudeepchat@yahoo.co.in

1. "of the people, by the people and for the people" - or at least, that's what they say.

2. I am not assuming leaving everythign to economics will solve things (corruption, for one, will still be rampant), but it will, in my opinion, improve the situation.

3. It does.

4. Good to know you work in the rural areas. Assuming it is "armchair rage", what's wrong with it? So should one have studied in a medical college and have worked in the rural areas before one can decide what's right and what's wrong?

zeya

"There's no harm in proposing it by force on those elite class." - See my reply above to dazedandconfused. I have two problems with your statement, the use of the word "force" and "elite class". Force goes against the very concept of democracy and the Human Rights declaration. It will start with this and it will only extend to things like what the Shiv Sena is doing in Magharashtra. You simply can't decide what is best for someone else. And I'm sure there are enough doctors who don't belong to your definition of "elite class".

freedom

Whether it is noble or not is a value judgement that I'm not willing to make, but I agree it is "evil".

anonymous

I'm glad you agree, but then you say "then this scheme might actually benefit the new grads. And, so it might be actually good." -- how can one decide what is good for another? For all you know, good for somebody else would be work in a air-conditioned hospital. You simply can't force individuals to do something just because somehting is "good" in your opinion. I'm sure similar arguments are used when parents force their children into marriages.

And yes, it is early since the idea is in the proposal stage, but then you never know.

vi

Yes.

musafir said...

anonymous

Yes, it is a little emotional in places, but thought out at the same time.

CMC is a private organization (correct me if I'm wrong). It can decide what it wants to do. And people, when they apply, know what they're getting into. Just because 1000s apply doesn't make it right, doesn't mean there are people who don't apply for the sake of not wanting to spend one year doing something they don't want to.

All I'm against is this being made mandatory by the Government.

randhir

Any counter-arguments are welcome.

musafir said...

PS:
everybody

Apologies for the typos, was in a hurry.

m (tread softly upon)

Make that "...people who call for involuntary social service"

The Soliloquist said...

I do not want to take sides here... But I do disagree with your arguments.

Starting with the basic question..

Why is serving in villages considered a "social service" ????

AFMC has a bond to serve in the army. should that also be deemed social service ? Or is the army a private wing of the public sector ? :-)AFMC produces some of the best doctors in the country and the entrance exam is very stringent, and the bond tenure strenous. Still students aspire to get into the instituition.

Maybe you are right about the risks involved in sending rookie doctors. That being the case, why not send MDs and post grads ? the need of the hour in our villages is quantity,not quality.And in this light, the move is indeed "Commendable". Brushing it aside as "leftist" is pure 'right'talk. :-)There might be follies in the finer details, and the scheme in its present form may falter in the long run, but policies, like everything else evolve.

I know of a person, who was inspired by the movie Swades, and postponed his FRCS for serving in a village hospital.When asked, that he can serve better if he comes back after his FRCS, he said that he might not have the mental makeup to serve in an indian village after he returns. He grappled for a year with lack of resources and corruption before moving into the city.

Most of today's solutions to 'Practical' problems have come from 'idealists'.And most of the time, these 'idealists' are apolitical policy makers, who let the politician take the credit for their brainwaves. (for instance, the officials behing Lalu's Railway reforms). We do have some very ethical and able civil servants amidst the general decadence that the arm-chair socialists harp about.

And there is absolutely nothing wrong in setting up communication networks and building generators in the villages. Afterall we studied to become engineers, not slaves to MNCs. Perhaps it would build the much needed aptitude for classical engineering that is sorely lacking in our colleges, and would encourage people to study for reasons other than to decorate their resumes.

The Soliloquist said...

Boy, u r going to regret giving me the liberty to post long comments :-)

musafir said...

the soliloquist

You're simply missing the point.

I don't have anything against people "serving" the population. In fact I would be happy if a lot of people "served". I'm against people being compelled to do so. Id on't have problems against "practical" solutions coming from "idealists".

And it is called "social service" because one is "serving" the "society" out of an interest in its upliftment, with monetary concerns being secondary. You could use another name. Semantics is never an issue.

AFMC, the guy going easy on the FRCS - again you're missing the point. AFMC is not the Government which is elected and people don't pay taxes to run it. People get into the AFMC and g oeasy on the FRCS of their own volition. And just like there are people who want to do such work, there are people who don't want to. There's nothing wrong in them wanting to make money and not "serve" -- to each his own. What's the point in asking such people to do such work?

Simply put, the bigger point is: Government cannot ask us to -- and neither force us to -- do anything that we don't want to. How difficult is that to understand? Where will this stop then? Have you heard about this scheme where women Government servants will be asked to submit details about their periods? Of course there must be some "reason" for that too, but then you're simply trampling upon the individual's rights.

The individual is sacred. Let him choose what he wants to do. You don't have the right to decide what's good for somebody else. End of story.

And calling someone "leftist" is not "rightist". It is just an expression of shock at a disguised opinion.

It is not too difficult to envision a scenarios where aspiring doctors don't take up MBBS simply because they don't agree with the Government ideologically.

musafir said...

the soliloquist

And yes, just because AFMC does something does not make it right. See my replies above yours for more.

As for " Afterall we studied to become engineers, not slaves to MNCs.", people choose to. Nobody is forcing them.

The Soliloquist said...

I ll come backwards front.

"It is not too difficult to envision a scenarios where aspiring doctors don't take up MBBS simply because they don't agree with the Government ideologically".

Beg to differ. It is difficult for me to imagine such a scenario. A mere one year compulsary rural service being a deter to MBBS aspirants is hard to visualise. It would probably be like an extended house surgeonship. These people look at a career spanning years. They need all the experience they can obtain to build practice. And trust me, our villages offer immense scope for these doctors to pick up on primary health care. So professionally too, they stand to gain.

"And calling someone "leftist" is not "rightist". It is just an expression of shock at a disguised opinion."

since when has leftist ideology become an expression of shock ? Do we equate it to Nazism and Fascsim? They would express shock. Communism is a grand idea gone wrong. But the crux of it is nevertheless grand. Both left and right have their pros and cons.

"The individual is sacred. Let him choose what he wants to do. .... End of story."

Yes, if we are talking philosophy, the individual is sacred. I am an individual.I am sacred. why should I pay tax for some X,Y or Z to become a doctor??? Close down all the Govt medical schools. (It costs our govt run instituites more to make a doc than what they collect as fees).

"Simply put, the bigger point is: Government cannot ask us to -- and neither force us to -- do anything that we don't want to... but then you're simply trampling upon the individual's rights."

I am not defending every policy of the government. It s never them against us. We are all in this together.
See the term "bond" might sound harsh. But when it becomes just another step towards becoming a full professional, still benifiting many, it is no big deal at all ! Lets not blow up things and get Ayn Randish.

"AFMC is not the Government which is elected and people don't pay taxes to run it." ?
"AFMC is not the Government which is elected and people don't pay taxes to run it."

Where do we think the money to maintain the army comes from??? IMF ???
Why do we place our javans who gaurd us against impending danger above our farmers who feed us day in and day out ?? Arent we being a trifle hypocritic here ?
"And it is called "social service" because one is "serving" the "society" out of an interest in its upliftment, with monetary concerns being secondary"

A one year rural service isnt going to cause a big monetary dent for a rookie medico.. These guys take quite a few years to see a profitable private practice.. And it also keeps village hospitals always ready for emergencies. No one is getting "served" here. The villages get what they have wanted for long. And the medicos learn more than what they can pick up by being resident docs in posh private hospitals. (the specialists run the business there, and resident docs end not learning much). Unless one is in deep financial crisis, one isnt hurt much.It is just an arrangement. There is no question of social service, be it voluntary or involuntary.

"And yes, just because AFMC does something does not make it right. "

Why havent we opposed that all along ? At the risk of digressing, health care in the US is amongst the most advanced in the world. But still its the most expensive and mostly inaccessible.Privatisation has not helped. Even the middle class suffers. Private hospitals give room to more covert unethical practices than public medicare.Medical Insurance companies ruthlessly cheat people and make them more pitiable than our villagers in a "devoloped right economy". The right of the individual is protected there. But humanity suffers.

"As for " Afterall we studied to become engineers, not slaves to MNCs.", people choose to. Nobody is forcing them."

We chose engineering, because everyone else did. We chose the IT sector because everyone else did. Do we call that "Choice" ? We just chose to run behind money and status. Perhaps that is our choice.

catch 22 said...

Shakes his head and leaves.

musafir said...

the soliloquist

One last time ...

"Beg to differ...So professionally too, they stand to gain" -- Why do you keep consistently missing the point? It is not an "internship" we're debating here. That is already happening. If the government wants its medicos to spend a year in the rural areas to "learn", where the Government will fund them, then I don't think I could argue over that. But no, that's not what is being usggested. What is being suggested is a sugar-coated form of cheap labour to solve a health-care problem. Doctors, wet behind the years, are being asked to take responsibiltiy over people's lives. Tehre is a difference between "education" and "labour". And what's more, they are not making it optional. they are making it compulsory. You seem to be missing that totally.

"since when has leftist ideology ... Both left and right have their pros and cons." -- Again, missing the point. Who cares what political stance people adopt? I said "disguised opinion". The Hindu paints itself as capitalist whereas most of its opinions are socialist. That's my problem.

"Yes, if we are ...they collect as fees)." -- See reply to dazedandconfused. Government's role in education is open to debate. I'm not getting into that. I'm okay with paying taxes for my place in society. The Government can use it as long as it is accountable.

"I am not defending every policy of the government...Lets not blow up things and get Ayn Randish." -- You aren't, but at no point are you asking the Government to clean up its act. And I think Doctors know how to take care of their professional careers without any help from the Government. Why should they be duty-bound to help anybody? Let it be voluntary. it's like the state sponsored provident fund. Why should the Government ask me to invest in a stupid scheme with very low returns and why does it think I can't take care of myself? Same analogy applies here. A doctor can further his career without any help from the Govt. And it doesn't need Ayn Rand to recognize individual rights. The Human Rights decalration itself is enough.

"Where do we think the money to maintain the army comes from??? Arent we being a trifle hypocritic here?" -- I neither follow your argument nor see the connection with the current debate. Again, ours is a voluntary army comprising of professionals. There is no conscription or draft. People are not forced to serve in the army. That should speak for itself.

"A one year rural service isnt going to cause a big monetary dent for a rookie medico ... There is no question of social service, be it voluntary or involuntary." -- How can you say what hurts and what doesn't? How can you think what you consider right applies for everybody else?

"Why havent we opposed that all along ? ... The right of the individual is protected there. But humanity suffers" -- Not at any point have I advocated Privatization as I'm aware of the issues involved. All I'm asking is for the Government to do its job.

"We chose engineering, because everyone else did. ... We just chose to run behind money and status. Perhaps that is our choice." -- Nobody forced me. In my dictionary, that means I chose, whatever my reasons.

catch22

:-)

Karthik said...

Joins Catch !!

On second thoughts, i tend to agree with Sol more.

"What is being suggested is a sugar-coated form of cheap labour to solve a health-care problem."

Sure, WHat's wrong with that?? The majority of MEdical college's in India are Government funded. And try studying at any private college to know the true cost of medical education. And what's wrong in asking someone to work an year somewhere - i am paying them money right ??

There are certain more things - All the developed countries have good NHS where doctors from countries like us take the rural postings while the native people take the lucrative urban practices. But can we afford something like that ? I entirely understand all your points regarding invidual, free will, right of choice etc - but we live in a country where people follow "herd" mentality, where oppurtunities are limited and aspirations high - so if a rationalist doesnt want to study MBBS in India - just because the govt has these "strings" attached - the govrenment is least bothered. There are thousnads and thousands of others who are waiting to grasp the oppurtunity .. And FYI - these people would be of more "use" to the society than a guy who studies medicine with a Government SUbsidy all the way through and jumps of to America or UK at the first given chance !! lets face it da - most of the country is filled with people for whom 'oppurtunity' matters much more than 'ideals' - and there's nothing wrong if the Government decides to extract it's pound of flesh !! After all wouldn't it be painful to see thousnads and thousnads of students studying in subsidised education and leaving for "greener" pastures ?? Can you show me any guy who before leaving to the USA returns back the money which the government spent on him as subsidy ?? As long as there is subsidised education, such things can be demanded !!

Forgive the typos :D

The Soliloquist said...

Your arguments basically attack the move from two angles :
1. its apparent short sightedness

Agree, it does not think long term. But, everything has to be tried and tested, before it is perfected. And when trials are to be on the field, the intensity of the repurcussions need to be considered and this scheme isnt poised to cause serious damages.

2. The right of the individual being put at risk.
My response as under:
"There is no conscription or draft. People are not forced to serve in the army. That should speak for itself."

So would be the new system. Would be a voluntary set of doctors who know that they have to work in village hospitals for a year to gain their license. And wouldnt probably mind it.


"A doctor can further his career without any help from the Govt."

Dont deny this. Wanted to point out that the situation is not all that dark as you had painted it in the post. That the docs arent being entirely exploited by the scheme. You try to bring out the negatives of this scheme, I try to see the positives. With the scarcity of the general practitioner in the cities, this kind of exposure would do the young medicos a lot of good.

We chose engineering, because everyone else did. ... We just chose to run behind money and status. Perhaps that is our choice." -- Nobody forced me. In my dictionary, that means I chose, whatever my reasons.

This is my whole point. Nobody is forcing people to take up medicine. No one is forcing existing docs to go into the fields.Its the new set of medicos who have to take this up. Just like adding another subject to the syllabus. And there's not a breach of human rights here.

3.As a sideline, critism aimed at the papers :

"The Hindu paints itself as capitalist whereas most of its opinions are socialist."

A newspaper is not expected to thrust its opinions beyond the editorial page. The rest is just news. The hindu does not declare itself to be capitalistic or socialistic to stick by it. Politicians and philosophers have ideologies to stick to. Not newspapermen. They just have ethics.

I have not been missing your point.I fully acknowledge it. And understand why you feel so. Just that I want to say, there is another way of looking at things.
And that this move doesnt merit so much flak.


P.S: Dunno if you are enjoying this, but I like arguing with you.You sound more rational than the rest, maybe :-)(Cant help bringing the personal element in :-))

musafir said...

karthik

I'd proposed an alternative to the subsidy issue in an earlier comment.

Your argument is this - Government is subsidizing the education, so it has the right to demand the one-year stint. You haven't answered any of the other points in the post.

I don't have a problem if the Government makes it optional. That would then put more impetus on the Govt. to make its jobs attractive. Why shouldn't it compete with other employers?

In an ideal world, I would ask the Govt. to stop subsidizing and get its ass out of education and get back to administration. But the argument against that is the Government should provide opportunities for everyone and hence it subsidizes. Extending the same argument of "providing opportunities" to the down-trodden, the Govt. should provide people the opportunity to study and not have to serve. If the down-trodden have a legitimate need to study, then so do I have a legitimate need to study without wanting to serve. Who are you or the Government to judge which need is greater? Once you start indulging in needs, you know how the argument goes.

But since I know ground realities, it is tough to ask the Government to stop subsidizing. But is the Government going to offer a student the choice between the subsidy-one-year-stint and the no-subsidy-degree-after-five-years? Why not offer students a loan and ask them to repay it once they start working? That is much simpler than a subsidy, isn't it?

My fundamental problem is against the forcing of choice. And what's worse, this will just make the playing field uneven. People in the private colleges will be able to do what they want whereas the Govt. doctors won't. And what will happen? the Govt. wil lend up making the rule universal just to "level the playing field".

You seem more intent on extracting that one year than considering the efficacy of the solution. This won't solve any of the exisitng health-care problems simply because there are just too many leaks in the system and zero accountability.

In my opinion, if you bring in accountability and transparency, the system will work just fine without having to ask doctors to waste one year doing something they don't want to. This scheme will only result in further rotting with doctors just doing something for the sake of doing.

And have you even stopped to ask what's with the one year? Why is it morally wrong to ask them to spend ten years in a rural area? One day or one year - doesn't make a difference.

And where will this go next? Why not extract something out of everything that is subsidized? Because it is morally wrong to subsidize something and expect something in return without offering an alternative.

You seem to lack the vision to see that once this is allowed, a lot of things will follow. Conscription, for example. The net has a lot of sites with excellent arguments against Conscription.

the soliloquist

1. Things can be judged without trying them out.

2. You are taking the liberty to talk for everyone. I'm afraid I don't agree. I think we will end up with a bunch of disgruntled people going through the motions. And you also seem to want to simplify this one-year stint into a "subject", where I again disagree. It is not an additional subject. It is employment at a lower wage than is possible on the Doctors' own. It is just good old-fashioned Nehruvian socialist exploitation.

3. No newspaper declares a political stance, yes, but then one expects a certain consistency of philosophy, a certain integrity in their opinions. I'm afraid that seems missing and they toe whichever line is morally safe. Capitalist one day. Socialist another. Even at the risk of contradiction. And that's where they lack ethics.

musafir said...

the soliloquist

Oh yes, I am enjoying this. Helps to crystallize my opinions and strengthen my arguments. Not that I take pride in taking a stance, just that sometimes one needs to stick to one's version of the truth. And it helps when there are people who leave long comments :P

Anonymous said...

Yesterday on reading this post I came up with a rather long comment (surprise!surprise!) in an uncharacteristic acerbic tone. But I did not post it because I realized I was not in the right state of mind which being preoccupied with the Virginia Tech idiocy. The problem with the arguments in your post is not that they are "wrong" . It is impossible to argue against it without painting oneself to a corner. But there are some glaring oversights ( read: Totally different "cube" of looking at it which can make one look at it in a different perspective and some logical and rational counter arguments are indeed possible which soliloquist has more than done justice to. ( *drumroll begins * on a side note I seem to agree with soliloquist without a murmur after almost 6 yrs now! :p * drumroll ends * ). I could just shrug my existentialiast shoulders and say "It is just a matter of perspectives" and move on. But the point of "individual freedom" from both a philosophical and pragmatic perspective could do with some armchair intellectual masturbation.
And pray what exactly according to you is "individual freedom"? how far can you(we?) play that card? If one is "forced" to become a doctor then one can claim that goes against the grain of I.F. No arguing there. But if one is "forced" to work in rural areas can you bring in the I.F. card? Extending this reasoning in an ostensible illogical way would you
trumpet that card if a doctor in a hypothetical scenario refuses to treat a patient? My point is I.F. is exercisable to only a certain extent. But if one takes up a position of responsibility one should be prepared to adapt to the changing situations. Though not so long ago I was an adherent of this I.F. off late I feel it is just an oft repeated excuse for lassitude and shirking responsibility. something I have been guilty of as well. And in what sense we are "free" anyway? Arent we all "prisoners of our own device" and that sort of thing? Choice is largely an illusion and Freedom even more so. But the philosophical ruminations and lashing of government's ineptitude aside , bringing in the utilitarian perspective I think we largely need somehting like this. A pragmatic solution will be to tie up the private doctors ( appeal to their "altruism" by giving them tax sops,do whatever it takes ) along with the neophytes and subsidize the medicines. At best these neophyte doctors will be like acolytes to the holy-docs. So be it.
Maybe I just have a very dim view of human nature but I think the time has come to set the ball rolling by certian strong measures *if* you are in certain professions than take refuge in subjective notions of individual freedom and universal human empathy. I might,ofcourse,crib,rant and mouth platitudes about I.F. but atleast will get some work done in this largely meaningless and absurd universe.

Are you surprised why Sartre had Leftist leanings? And Camus to some extent?

Lets face it "mankind" is not what it used to be.

Karthik said...

ok - before i start, i clarify that i am no nehru-gandhi supporter.

You seem to be missing the historical perspective to the whole issue. In case you landed from the moon yesterday, lemme remind you of what has happened in india in the past 50 years. Britishers came, conquered, looted and left India (in shambles ??). At that point over 3/4ths of the country was illitreate and was in misery. nehru didn't really have a choice but to embrace the socialism model and the government ***had to enter the education sector***. Things werent much better in the 60's or 70's. By the end of 80's and early 90's we started showing signs of revival. Our economy slowly came out of "beg" mode and all the progress which you see today is something which has happened in the last 15 years. And i still think that at that juncture what nehru did was right. Where were your capitalists when India was starving - they were busy making money in latin America and east Asia. And still parts of India are in a bad shape - where education, healthcare and litreacy are pipe dreams. Keeping all these things in mind, speak about Freedom of choice and man's power to choose and also judge the "HINDU".

I agree socialism(in the context of the discussion)isn't the best solution. But neither is capitalism - private healthcare and the raising costs are killing more people. The government doesnt have a magic wand - to just wave it and create spanking new hospitals in Gobichettipalayam and Tirunelveli and man it with the best of specialists. Heck - the doctors in india aren't blind - they know all the problems happening around them. So cant they spare some time from their successful practices and help poor people ? Do they do it only when some religious godman creates a trust and asks them to work for it ??

Well - FYI my cousin is a freshly passed MBBS graduate. He is busy preparing for his specialisation entrance exams. he told me that it's mighty difficult to get a seat. The government has a scheme whereby if you work for 2 years in a primary health care centre, you get a special quoto for your PG. Still Still most people opt out - beacuse they find the whole idea of serving in a Primary Health Centre in some remote village "unappealing". They all want to work in a swanky hospital which has 24 hour coffee shops and serves the elite of elite, not a place where poor people come with no money but plenty of problems. Pray - it's the same human body .. Why this partiality ?? And FYI - he studied in a Government college where the fee was 3000 per year. The government invests money on him hoping that he would be more sensitive to his fellow country man - and as long as there are such people who are motivated solely by money - there's nothing wrong in the governments decision.

Phew !!

The Soliloquist said...

Goody Good... The argument heats up.. M enjoying it even more :-)

@musafir:1.things can be judged before trying out. But not in whole. And when it involves multiple variables, experimentation gives a better picture.All I am asking, is this policy too should be given its chance.
2."I think we will end up with a bunch of disgruntled people going through the motions"
We all are disgruntled people going through the motions, arent we ? Sounds a little feeble in the present context.
Yes it is another subject, something akin to the mandatory industiral internship that other professional instituites demand. It gives the young medicos a feel of the real world, where medicare is a need and not a privilege.It does not hurt to simplify things that are simple.
As for The Hindu, the present condition of our media is very dismal. As long as a paper doesnt misinform or distort news, it should be considered holy. True, that I too find the much admired neutrality of Hindu missing, since the editor's desk has seen a change. But as long as the discerning reader is able to form his or her own opinion, I should say the daily's job is fine enough. Weighing against the TOI and the visual media, The hindu is atleast not an assault to the senses.

@ anonymous:

Thanks for the drumroll :-)
People tend to agree, when their frames of mind matches.. We all go through our own cycles.:-)

"Lets face it "mankind" is not what it used to be. "

Good one.. :-) Especially the time reference being implicit... :-)

@karthik:

"Do they do it only when some religious godman creates a trust and asks them to work for it ?? "

Something that I too have always wondered, but let pass, cos something worthwhile was getting done by someone.. The means taking the backseat..

~A said...

If "free will" at stake is the inherent problem of this scheme...isn't it at stake almost everywhere?

musafir said...

~a

It is.

Anonymous said...

...and the possibility of Free will existing is largely disputatious...maybe we are committing the intellectual faux pas of bringing in philosophy and politics together. Something which man has been guilty of since time immemorial.

musafir said...

anonymous

From "Philosophy: Who Needs It?" by Ayn Rand -

"Philosophy studies the fundamental nature of existence, of man, and of man's relationship to existence. As against the special sciences, which deal only with particular aspects, philosophy deals with those aspects of the universe which pertain to everything that exists."

"The nature of your actions-and of your ambition--will be different, according to which set of answers you come to accept. These answers are the province of metaphysics--the study of existence as such or, in Aristotle's words, of "being qua being"--the basic branch of philosophy."

"The extent of your self-confidence--and of your success--will be different, according to which set of answers you accept. These answers are the province of epistemology, the theory of knowledge, which studies man's means of cognition.

These two branches are the theoretical foundation of philosophy. The third branch--ethics--may be regarded as its technology. Ethics does not apply to everything that exists, only to man, but it applies to every aspect of man's life: his character, his actions, his values, his relationship to all of existence. Ethics, or morality, defines a code of values to guide man's choices and actions--the choices and actions that determine the course of his life."

"The answers given by ethics determine how man should treat other men, and this determines the fourth branch of philosophy: politics, which defines the principles of a proper social system. As an example of philosophy's function, political philosophy will not tell you how mush rationed gas you should be given and on which day of the week--it will tell you whether the government has the right to impost any rationing on anything.

The fifth and last branch of philosophy is esthetics, the study of art, which is based on metaphysics, epistemology and ethics. Art deals with the needs--the refueling--of man's consciousness."

That should explain the role of philosophy in politics (The rest of that speech is here - http://gos.sbc.edu/r/rand.html). Free Will being disputatious, the Government has no right to assume it doesn't exist. Existence, or non-existence fo Free Will, is a personal answer.

Would appreciate it if you took your comments offline. I won't be checking this space anymore.

Anonymous said...

Well not that I disagree with this exposition of Rand's definition of philosophy but I have to be a starry eyed 15 year old just to take in Rand without a murmur..

And I have read this mmm..ages ago.
comments offline? why might one ask?

The Soliloquist said...

Did that ! :-)

Doctor Bruno said...

Before buying that stupid argument that government subsidises medical education, please read my post at http://bruno.penandscale.com/2007/01/my-two-seconds-of-fame.html

Doctor Bruno said...

I have examined this issue from both points in my blog post at http://bruno.penandscale.com/2007/04/1-one-year-rural-posting-after-mbbs.html

Doctor Bruno said...

//4. If you look at it from a corporate angle, our villages being customers would end up at the receiving end of very poor service. //

They are not replacing MD doctors with MBBS Doctors... They are replacing "No" doctor with "MBBS Doctor"... So this argument is not valid

//Why should they accept this scheme? Because the system is in such a sorry state they will be happy to get anything that comes their way, instead of rapping the government on the knuckles for suggesting this hare-brained scheme.//
I accept this

//5. Why are the doctors and the medical associations keeping quiet? Why aren't they protesting? //
Please see the bond every doctor has to sign before getting MBBS Admission.... Then you will know the answer

Institutions like CMC Vellore and AFMC have used the bonds... Other colleges have so far NOT Used...


//Where are all those placards and those marches? //
!!!!

You seem to have analysed everything from the Corporate point of view..... While I am not disagreeing with you in many issues, I am afraid that in few of the issues, you are wrong by a large margin....

Doctor Bruno said...

Though I am a strong advocate of Rural Service, i can't understand the logic behind asking those not willing to come to villages
The truth is that even with the present amount of doctors, the health care can be improved if we attend to few other factors.

It has been the practise of policy makers to point the finger at the doctor (or lack of doctor) for all the maladies in Indian Villages

The problem in of Health Care in Rural Setup is not just lack of Doctors............

It is lack of

1. Facilities

There is no use in asking a Doctor to go to Village giving just half a dozen drugs (Para, Septran, Avil, Albendazole, Chloroquine and Inj B Complex)

2. Lack of awareness by people

The rural public will not come to "english Medicine" as soon as they have an ailment...... First they will take thier own (grandmother suggested) medicine. Then they will go to a quack (the doctor posted in PHC is mostly young, where as in the opinion of the village public the quack being old is more experienced Smile)... Then they will come to the Primary Health Centre and when you cannot cure them INSTANTANEOUSLY with the available drugs, they will go to the General hospital

3. Lack of Infrastructure

Most of the Primary Health Centres are located well out side the villages some places even 3 to 4 kilometres with no bus (and some places even no road Smile) How can you expect some one with pain to come there. They will obviously catch a bus to go to the near by city hospital

4. Lack of Working Knowledge by our Medicos

And then is another problem, from our side. We doctors will not give Injection (fearing AIDS) for cases not indicated. Where as the Quack will give injection (some times even 2, and charge for both Smile)

Bottom Line 1 : Rural Service is NOT as bad as it has been projected
Bottom Line 2 : Nothing is going to change by JUST posting MBBS graduates at Villages without amending the main Issues

Doctor Bruno said...

So what is to be done

1. Government has to look at the other issues AND DO THE NECESSARY ISSUES while posting doctors

2. Doctors should be posted only after (at least 15 days of ) management training which is needed when you are working alone in a remote place

3. Make sure that the fresh graduates are posted in PHCs and CHCs which are well connected by Bus or Train (Other wise, no one will go !!)

What has the graduates do

1. Think this as an opportunity to learn managerial skills which will be definitely needed to run their own hospital in future (I am not telling that to learn managerial skills you have to come all the way to PHC- Don't take it as that way) I am only suggesting that PHC will teach a young doctor a lot more that is needed for a doctor than what is being thought from AC Rooms

2. Try to be a HEALER than some one who just diagnoses and treats

3. Ask the government to post them across various institutions like PHC / CHC / WCH / Sanatoriums / NTKH / TK H / DHQ H etc so that they have a wide exposure

4. Prepare for Post graduation Entrance Exams while being posted there