The government is planning to introduce a new course-B.R.M.S(Bachelor
Of Rural Medical Service)to cater to the health care needs of rural people.
While it may seem to be a novel and practical idea, the move is fraught with
many risks. As a doctor who had worked in government primary health center in a
typical rural Indian village I like to share some of my concerns in this
regard.
Firstly, the very basic conception of primary health care and
rural health care is being grossly misunderstood. It is very naive to believe
that rural health care need is all about treating common cold, viral fever,
body ache etc. Morbidities like heart diseases, renal diseases, neurological
disorders, rheumatological diseases etc and not to mention emergencies of all
kind(acute myocardial infarction, stroke, poisoning etc) are all nearly as
common in rural places, if not more than in any other place. Even quacks can
treat many diseases with a cocktail of powerful antibiotics and other
irrational combination of drugs. However the most important attribute of a
doctor is the trained eyes of a discerning mind to pick up a disease at an early
stage and the timely & appropriate institution of primary and secondary
preventive measures to prevent the emergence of potential public health problems.
This is especially crucial in rural areas where the number of a contacts a rural
patient will have with heath care professionals is only a few times. It is a
fact that even MBBS doctors in primary health centers find it challenging in
the early diagnosis and management of the above mentioned complex cases and
most cases are treated by referring them to taluk and district hospitals for
specialist opinion.(that there are no specialists there is a different matter.
In fact there is acute shortage of specialists and super specialists in the F.R.U.s-first
referral units- and district head quarters hospitals). So can a BRMS professional
do justice to this seemingly simple but a highly technical job?
Second. Health is a sensitive issue and deaths are common in any hospital
setting including P.H.C.s. If a death occurs in a BRMS manned P.H.C inspite of
the BRMS doctor following the correct treatment protocol(which is quite a
common possibility-for example when a patient comes late after a poisoning,
snake bite, etc) there will always be a doubt among the community if the death
could have been prevented had a regular doctor been posted. The fundamental
trust a patient has for a doctor will be undermined and this may lead to
dangerous consequences. Imagine for example the 24 hours news channels flashing
headlines-'one more death in a BRMS manned hospital(something like -one more MIG
crash). Is the government decision to introduce BRMS short sighted? etc etc.
This may lead to prejudice against the BRMS professionals and may upset the
entire plan.
Third. For students who opt for BRMS after plus two, what is the scope for
their upward mobility? Will they be allowed to do MBBS or P.G.degree at a later
period? If yes then there is no point in having the new course-after doing MBBS
they are not going to settle in villages just like the present situation. And
in case if the BRMS is going to be a dead end career option, how the government
is hoping to attract talent?
Fourth. Readers should also note that a diploma in nursing is for 3 years, Bsc
nursing is for 4 years and significantly Ayush doctors are trained for 5 1/2 years.
This may lead to organizational problems. Will a BRMS professional heading a P.H.C.
be able to command effective authority over the subordinates to carry out the
enormous responsibilities of a PHC medical officer?
Fifth. There is already a turf war going on between Allopaths and Ayush practitioners.
Is it wise to create an another class of professionals in this category? It is
highly likely that BRMS doctors will be discriminated against by both the
allopathic and Ayush doctors(it is better to have a class divided society than
a caste divided society. But we should avoid creating multiple classes arising
especially from the ad hoc measures of governments.)
At this juncture it is worthy looking at some of the other models. Tamilnadu
has already declared that it does not need the BRMS course as almost all the PHC
s in the state have atleast one MBBS doctor and there is enough competition for
fulfilling the remaining vacancies. But we have to acknowledge that the
situation is not the same in all the states.
There was a proposal some time back for compulsory rural postings for MBBS
students for one year before they can receive their degrees. This proposal is
good but needs a major departure from the present scheme of things in which it
takes a frustatingly long time for medical graduate to finally settle down in life.
After 5 1/2 years of MBBS they toil hard for 1 to 2 years preparing for the
highly competitive P.G.entrance exam. Then after 3 years of P.G course a
feeling of incompleteness and inadequacy still persists, especially in the
present competitive world, forcing many of them to prepare for the still highly
competitive entrance exam for a further 3 year course in super specialty
degrees. By the time they finally settle it is well past 30 years of age and
when they look back, to their dismay, they find that they have spent most of
their youth sitting in chair reading increasingly bigger and bigger books. They
cant help but get the feeling "is it worth having studied so well in plus
2 and land up in medicine? So it is not wise to burden them more. So is there a
way out? Yes.
The
entire medical education system in our country is crying for a comprehensive reform.
There is a case for reducing the course duration of M.B.B.S from the present 5
1/2 years to 4 1/2 years and when this is done one year of rural postings may
not be unacceptable (as most students dont stop with U.G alone, at the MBBS
level, the curriculum can focus on diseases prevalent in India alone as against
the present situation where students study mostly foreign author books which
contain detailed descriptions about many western diseases which are rare in India).
Infact young graduates dont have many commitments(like educational needs of
their children etc). Also it may be a different learning experience for them
besides being enjoyable and adventurous. So the one year compulsory rural
posting idea can work out if it is incorporated within the existing 5 1/2 year U.G.
curriculum ie without any additional
time period requirement.
At a parallel level urgent steps need to be taken to address the root causes
why doctors dont prefer to settle in rural areas. Good quarters need to be
provided for rural doctors; also extra monetary incentives and reservation in
postgraduate courses etc need to be given to them and more importantly rural
infrastructure need to be vastly improved- from roads to schools to drinking
water- everything needs the required investment to expect a medical graduate to
work there. If rural infrastructure is not improved even BRMS doctors are not
going to stay there in the long run. Wait. This is not an imaginary
possibility. In Tamilnadu in many PHCs even the V.H.N.s(village health nurses )
dont stay at village health subcentres where they are supposed to stay and they
come for duty from nearby towns where they feel their children can get good
education. It is already proving to be very difficult at the ground level to
strictly enforce that provision.so the big question comes- if V.H.N.s dont stay
in villages can we expect a BRMS doctor to stay in villages?
One may say that all this-improving rural infrastructure- will take time and we
need something like BRMS as an interim measure. This takes us to the other
important issue. Even in states like Tamilnadu where most PHCs are manned by
MBBS doctors, the health indicators like MMR, IMR, Under five mortality,
prevalence of nutritional anemia etc are not something one can boast about and
are very very high compared to developed countries. The real problem lies in
the inefficiency of governance and administration (at all levels from
secretariat to the PHC level). Because the district health officer is corrupt
and lax ,doctors dont fear to go late and come early and because the medical
officer is insincere he/she loses the moral authority to discipline his/her
subordinates and the whole system just goes on heavy with inertia and
absolutely lacking in initiative and proactiveness. So with this present state
of affairs what is the guarantee that the new proposal alone will succeed? The
government cannot bypass these real issues by coming out with a glamourous
solution in the form of BRMS.
However the most important argument against the move is that it will lead to
missing a golden opportunity for a systemic review of the entire health care
system in our country including reforms in medical education. If a patient
comes with fever prescribing paracetamol alone will not help.it is necessary to
identify the underlying cause (eg-infection) and treat it. Similarly it is high
time we address the root causes of poor rural health care system including the
issue of why doctors are not prefering to work in rural areas. If not ,there is
grave risk of BRMS being considered as the ultimate reform in rural health care
and it will drive our policy makers into deep complacence and the real issues
will remain unaddressed forever. We study history that Gandhij opposed separate
electorate for depressed classes because, once that happened they will remain
depressed classes for ever and the question of abolishing untouchability will
get undermined. Similarly in the long run this ad hoc move by the government
will lead to the ultimate divide between rural and urban India -all MBBS and
allopathic specialists will settle in urban areas and rural India will be left
to the expertise of BRMS professionals. So, lets say NO to BRMS. The Government
should reform medical education, take
students into confidence and we can institutionalize an effective and efficient
rural heath care system.
This is a rare and golden opportunity to act towards a holistic review of the
system, because if not now-god only knows- it may take another 2 or 3 decades
for a next review of the system.
