Sunday, September 30, 2012

Why doctors don’t want to work in rural areas

The government of India is planning to launch a new medical course called B.Sc. Community Health, which will be of three and a half years duration. This new cadre of health personnel will be trained at District Hospitals and will be posted in Sub Centres and Primary Health Centres in the villages. They will be trained on diagnosis and treatment of basic medical cases. The idea the government clarifies is not to produce mini-MBBS doctors but to produce a work force to address scarcity of trained health manpower in the rural areas. The Times of India reports that this is to address the ‘menace of doctors unwilling to serve in rural areas’. Health Minister Ghulam Nabi Azad expressed his disappointment in a similar vein stating that young doctors are unwilling to work in rural areas. He says, ‘As the health minister I can make policies and the state government has to implement... and put some kind of genes in doctors to change them, otherwise I cannot do anything’.

There is truly a huge rural urban gap in availability of health manpower in India. Only 26% of doctors work in rural areas serving 72% of the population. Public Health Foundation of India estimates that in India, health manpower (doctor, nurses, midwives) population ratio is 8/10,000 against WHO recommended ratio of 25/10,000 population. 70% of the health manpower is in the private sector out of which 80% work in urban areas. Doctor population ratio in rural areas is 3/10,000 population while it is 13/10,000 for urban.

The government has tried several times to make doctors go and work in rural areas. One of the most common methods is to plead with the doctors to go and work in rural areas. In Nagaland, whenever doctors have their conference or meeting, they are urged to serve with dedication, theirs being a noble profession, and so on and so forth. Another way is to make it compulsory for fresh doctors to work in rural areas. Policy for rotation of posting place has been tried but failed in implementation. Financial incentives, assurance for regularization of job (for contractual doctors), and additional marks in PG entrance exam are also tried in some places. But through it all, why is it that the government has never tried to ask and understand the simple question, ‘why are our doctors not willing to go and work in rural areas? Not that we don’t have answers to the question. Answers are clear and simple, but we have always simply blamed doctors for ‘not willing’ and we never asked why.

So, why are doctors not willing to work in rural areas? There was a study called ‘Why Some Doctors Serve in Rural Areas: A Qualitative Assessment from Chhattisgarh State’ which was conducted jointly by Indian Institute of Public Health, Delhi; Public Health Foundation of India; National Health Systems Resource Centre; and State Health Resource Centre, Chhattisgarh. Instead of asking why doctors are not willing (the answer which I think seem too obvious), the research topic was ‘Why some doctors serve in rural areas’. They asked what the reasons are that make doctors remain and continue to work in rural and remote areas. The study may have lessons for Nagaland given that it was conducted in rural areas of 8 districts where a third of the population is tribal. Moreover, the low density of health manpower, hard to access geography, and problem of insurgency are common experiences. In-depth interviews were conducted among doctors (contractual and regular, male and female, graduates and specialists) serving in Community Health Centres and Primary Health Centres which are poorly connected to the district headquarters. Though it was not the main research focus, the study highlighted the factors that deter doctors from working in rural areas. They are:

1.      Low salary and little incentive to rural doctors.
2.      Poor access to training and upgrading of knowledge, and erosion of professional skills
3.      Lack of educational facilities for children and job for spouse.
4.      Lack of electricity, water supply and housing.
5.      Lack of equipment and supplies for clinical diagnosis and treatment.
6.      Lack of job security for contractual doctors.
7.      Threat to personal security due to insurgency.

These factors need no elaboration. Respondents reported experiences of social isolation and loneliness besides the material discomforts. There is lack of avenues for society and entertainment and some of them experience anxiety, depression, and alcoholism. Many of them live alone, as spouses and children are sent to towns and cities.

So, what is it that makes them stay on in their places of posting? But before that, how did they come to be where they are? Many answered that going to rural place was not their choice. There is corruption in allocation of posting places and since they do not have personal influence or good contacts in authorities to lobby for them, they were sent to rural areas.  Some of them chose to be where they are because of geographical and ethnic (tribal) affinities. Some of them chose rural posting as an obligation to the government for paying for their medical education. Some others cite religious reason to serve people. In most of the respondents, a combination of the above factors is responsible for their going rural. What makes them stay on? Some of the reasons are:
1.      Geographical affinities: Many of the respondents have a rural upbringing. The villages are not unfamiliar and village life is therefore not very uncomfortable to them.
2.      Personal values of service: Selfless service to the poor is a driving motivation to work in rural areas. Respondents feel that they are needed and their service is of value. This brings a sense of fulfillment and job satisfaction that makes them stay.
3.      Familial values and religiosity: The values that are passed from parents to serve and the villagers treating them as family are also factors which make them stay. One medical officer remarked, ‘it is religious work but you can earn money at the same time’.
4.      There were other factors like distaste for commercial enterprise, availability of work for spouse in the same or adjacent locations, availability of good schools for children, reduce in security threat, good relation with colleagues, etc. A number of them simply get used to the place over time (acclimatized) and stayed on.

When asked what their needs are, some of the replies are:

·         Improved work space arrangements and resources.
·         Better housing
·         Schools for children
·         Need based - training and skills development
·         Assurance of job security (for contractual) and better salaries

 The push and pull factors of doctors moving from rural to urban areas and what can be done to address them, given by WHO, are given in the table below:

Category of retention  intervention
Push factors
Pull factors
Education and regulatory interventions

     desire for further training
     lack of appropriate skills
     desire to get international
     access to continuing medical
education and professional

Monetary compensation (direct
and indirect financial
     poor remuneration
     lack of private sector or
opportunities for moonlighting
     better remuneration
Management, environment and
social support

     poor working and living
     lack of clear career profiles
     lack of schooling for children
and jobs for spouses
     work overload
     lack of management support
     emotional burn-out
     decline of health services
     political conflicts and wars
     social unrest

     improved standards of living
     improved working conditions
     opportunities for education of
     better supervision

Dr. S Rajasekaran argues that the reason why doctors are not willing to work in rural areas is not solely due to lack of personal comfort. He says, ‘There is a great misunderstanding amongst the public that doctors are reluctant to go to rural areas for lack of comfort. While this may be partially true, the bigger truth is that there is nothing more frustrating to see a suffering patient in front of you and you cannot do anything good for them even though you have the skill but the facilities are lacking… Lack of drugs and infrastructure are as serious as lack of personnel’.

The Chhattisgarh researchers conclude that not just patients but care-givers need to be cared for. In Nagaland, there are doctors who work sincerely in rural areas, in spite of all the personal discomfort and lack of facilities to optimally practice their skills. Not all of them are Governor’s gold medalists. But they quietly carry out their duties to the best they can. And we no doubt have people who are unwilling to work wherever they may be posted. In the middle are the majority who want decent working conditions with facilities and supplies to enable them to practice their trade. Like any other citizen in a modern society, they have professional dreams and family concerns. If our doctors should be judged, it should be after the basic needs and decent working environment are provided. Some people may willingly sacrifice their aspirations and serve in odd conditions. But in a modern democratic society, one cannot expect all doctors to go out and live heroic lives fighting against all odds and achieving only a fraction of what they are capable of.

Saturday, September 22, 2012

Why I write...

Reader’s Digest says that good writing is simple ABC: Accuracy, Brevity, and Clarity. I took that to heart. Another advice is to keep the language as simple as possible. So, I try to write in a language where readers will not need the dictionary. I break down complex words and shorten sentences. I follow certain rules that I learned from other writers, for example: never fall in love with your first draft, break the rules but after having learned the rules, to be a writer there’s no other way but to write, and so on. That’s how I write.

I remember how I started writing my thoughts. My dad who was also my headmaster made us write essays. In one class, he decided to read out one essay. He said that one of us wrote it but he won’t tell who. As he started to read the essay titled ‘My Neighbor’, my ears started to warm up. It was mine. Dad might have noticed my discomfort and he made sure that no one knows it’s me and he remarked in the end, ‘It is a good essay’. When other students were taking mathematics tuition, he encouraged me to take English grammar tuition. My English teacher was as also an inspiration. He made grammar more like a work of art than boring rules to be swallowed. He made me want to be a journalist one day. That’s what a good teacher does; he/she inspires. Though I went into Science stream, because of these two guys, I continue writing to this day. By the way, after PU Science, I had a plan to do BA English if I do not clear the MBBS entrance exam. So, that was how I started to write.

But if I am asked WHY I write, I don’t have a good answer. I write. Sometimes, I push myself even when no one’s asking me to write anything. I have no published book, no journal article, nor any technical background or training in writing. It is not for fame or name. I’ve been writing long before I put any of my writings in public. I don’t feel any divine calling that I have to write. I don’t feel I have been blessed with any special message to tell to the world through the written word. My job doesn’t require me to write that much. But I continue to write regularly. Sometimes I write as if my life depends on it. So, if not for the love of it, there’s no other concrete reason why I write. But I believe that love for the art will suffice and there need be no more reason.

Writing is hard work. Dry spells, aka writer’s block can drain you out. You squeeze and squeeze but the juice wouldn’t come. You stare at the blank page/screen, look up the ceiling for inspiration, search your heart; scribble, scribble, cut, cut, nothing. Then there are those days when your hand struggles to put into words the overflowing thoughts in the mind. Those are the truly exciting times. You didn’t know you have all that in you and you think you’ve wrote a masterpiece. But... Sleep over it and you find the next morning that it was nothing extraordinary really. You polish, sweep, stitch, repair, and get irritated. Some pieces that you were so excited about ends up in the dustbin. What a waste. Sometimes, the piece you are writing takes a turn midway and ends up very different from how you started. It is like you wanted to draw an apple but end up with a mango.

A writer is a keen observer. At all times he’s taking notes internally. A writer is also a reader. To write a piece, one has to read ten times as much. Then copy paste, copy paste :-) In an age when plagiarism is frowned upon and intellectual property rights violation has become a serious offence, one wonders if there is anything genuine to say. Whatever you know, someone already knew. An idea strikes your mind and you think it’s yours, but someone probably had written a book on it. It happened to me not long ago. I thought I came up with a beautiful motto for an NGO we were starting. We accepted it unanimously. I swear the idea was original. But when I went home and googled, lo and behold, it was already there. But the beauty of writing is that no matter how many people has written on the subject, no one has written it quite like you. No two persons see the same thing. There’s no one who has the exact perspective as yours. Therefore there’s always something fresh about what you dig out from within you. If that’s not true, we should be sick and tired by now of the hundreds of thousands of love song lyrics which talk of more or less the same thing. That same old Love that we know so well about.

Writing to me is a compensation for not being able to speak well. Good speakers are persuasive and some people’s jokes are funnier because of way in which they are said. As an escape, I sought solace in the written word. And like a pilgrim who has found his inner self (not that I know any), I found liberation in the written word. Some people pick up the microphone. I picked the pen and in so doing, discovered my voice.

Sunday, September 16, 2012

Zero Bulb Ideas (3): Background Music Bible

Zero Bulb Ideas is a series featuring whacky ideas of a noodle-headed nincompoop.
Waterproof Bible was in the news a while ago. There is no news or statistic thereafter if reading the Bible in the shower has increased or what is the percentage of ministers using it during water baptism. We have a host of other Bibles like Cowboys Devotional Bible, Soul Surfer Bible, the colorful Rainbow Study Bible, Good News for Modern Man, Super-Heroes Bible, Outdoors Bible, Woman Thou Art Loosed Bible, Students Bible, The Grace for the Moment Study Bible, Women Bible, Brides Devotional Bible, Couples Bible, etc, etc. At Bamora, a new Bible called the Background Music Bible is conceptualized. The idea is to use background music to create the right mood for the passages being read, so that readers can connect emotionally with the biblical text. A Bamora church believes this will increase spiritual fervor of readers and make reading the Word of God an enjoyable experience. For example, in the creation story of Genesis 1, sounds of birds and animals and flowing rivers will be used to make the readers feel connected to the creation of God. When Israelites go to war, fast pulsating music will be used to create a sense of war. When God spoke from Mount Sinai, sound of thunder and rolling drums will be played to create a sense of awe.

All pages are fitted to a micro digital music player. When the readers turn to a particular page, it automatically turns on a relevant music which is played in a mini speaker fitted at the top of the Bible cover. Readers can also use a headphone to listen quietly at home when they have their devotional Bible readings.

However, there’s a technical problem. When a page is turned, how do the Bible recognize which portion is being read? Say, in one page, there are psalms of praise as well as psalms of lamentation. So, when such a page is opened, what type of music should be played; music of praise or lament?

Saturday, September 15, 2012

Child Mortality Statistics: Not just numbers

For Eastern  Mirror column

In my presentations, I point to the health statistics and say that these are not just numbers in a table, shades of colors in a chart, or dots in a map; but they are measures of human suffering. Behind such mathematical and statistical figures of our health and disease data are real people who either suffered or died. Chances are that in the process data entry, compilation, and reporting; health statistics can lose sight of this and reduce human suffering to nothing but statistical data to measure performance of various policies and programs. I say this, to also stress on the need for reliable data, because those who manipulate or give false reports are not simply playing with numbers, but with human lives. It is also a motivating force for me that even though I don’t work in a hospital anymore to treat patients; through the use of health data, I try to study the dynamics of human health and think of ways to lessen human suffering and death.

Everybody dies. But to let children die in millions from easily preventable causes is a heartache that the world still faces. The new UNICEF report released few days back is another one evidence of that sad reality. According to the report; last year, 6.9 million children died before reaching their fifth birthday. What is most disturbing is that out of these, 4.4 million kids died from diseases which could have been prevented.
The leading causes of the under-five deaths are:
1.      Pneumonia: 18%
2.      Preterm birth complications: 14%
3.      Diarrhea: 11%
4.      Complications during birth: 9%
5.      Malaria: 7%

These are not conditions which are difficult to treat or prevent. Yet we still let children die of these in millions. The report adds that more than a third of all under-five deaths are attributable to malnutrition. Improvement has been made but it is estimated that at the present rate, the Millennium Development Goal number 4 (to reduce under-five mortality by two-third between 1990 and 2015) is going to be missed. 24% of these deaths (maximum) occurred in our country. Our State of Nagaland fare better when compared with the national average. It is interesting to note that in Nagaland, in spite of the fact that the percentages of pregnant mothers who go for antenatal check up, mothers who deliver babies in health centers/hospitals, and children who are fully immunized, are all poor; Infant Mortality Rate (IMR) is two times lower than the national figure. IMR for Nagaland is 23 (No. of infant deaths per 1000 live births) against the national average of 47 as per Sample Registration System bulletin, December 2011. 

The State Human Development Report 2004 stated that low IMR can be explained by the unique culture, social capital, and dietary behavior of the Naga society. So, reducing IMR is not solely based on the provision of health services, but social and cultural factors also play a big role. Social, Economic and cultural conditions/ environment which improve health must be encouraged and actively promoted. However, from the trend over the years, it has been seen (see chart) that IMR for the State has stagnated while the national average has experienced steady decline. And 23 is still an unacceptable figure given that Goa has only 10, Kerala 13, Manipur 14, and other developed countries have lower levels. This demonstrates that factors which influence overall health status of infants are multi-factorial. The health services delivery has to improve given the poor service delivery indicators.

From the National Family Health Survey third round (NFHS III) which was carried out in 2005-06, it was observed that in Nagaland, children deaths are related to the educational status of the mothers. A child is more likely to die before his/her first birthday if the mother has received no formal education. So, protection of a child goes way back to sending the girl child to school. Kerala is a case in point where because of its high female literacy, reproductive and child health indicators comparable to those of developed countries can be achieved.

The quality of care that the mother receives during pregnancy is very important for the health of the child. The government is providing free antenatal check up and medicines like Iron and Folic Acid. Also cash incentives are provided to promote institutional delivery for the safety of both mother and child. The father also needs to be sensitized on the importance of maternal care and identification of complications in pregnancy as the NFHS found that majority of the fathers in Nagaland were not sensitized or informed on these things. Also too narrow spacing of births, or pregnancy before 20 and over 40 years of age are found to be related to infant deaths.

Vaccination against Polio, Diptheria, Whooping Cough, Tuberculosis, Tetanus, Measles, and Hepatitis B are made available in the health units. But the percentage of children who have received full immunization as per schedule is still low. The community must come forward in a bigger way to sensitize parents to ensure full immunization of their children.

 Early diagnosis and prompt treatment are important to prevent deaths. Children are more susceptible to infections and their bodies have lower immunity to fight illnesses and survive complications. Among the leading causes leading to death of under-five children listed above, pneumonia, diarrhea, malaria, etc are easily treatable when diagnosed early. But they lead to death because of delayed treatment when complications have set in. Increase in health consciousness and change in health seeking behavior through education and awareness on the one side, and improved services delivery on the other are required to tackle preventable deaths.

India has more malnourished children than Sub-Saharan Africa. Ironically in the face of poverty, tons of grains rot in FCI godowns due to abstract market and political complications. The paradox of India is that stunted, wasted, and underweight children live side by side with the stingiest billionaires in the world and a consumerist middle class whose mind is set on his own self interest. Although nutritional status of children in Nagaland is better when compared to the National average, NFHS III showed that 32.4%, 15.3%, and 31.8% of children under 3 years in Nagaland are stunted (too short for age), wasted (too thin for height), and underweight (too thin for age). These children are more likely to get sick, slower to recover, and die more often. Malnutrition can also affect mental growth and reduce ability to learn in school. Proper nutrition during pregnancy of the mother, and during the growing stages of the child are important to maintian a healthy adult life.

The hard statistical data as in the UNICEF report, the National Family Health Survey, and other annual reports and surveys must be translated into stories and lessons that guide us to plan what we must do to reduce human suffering and improve wellbeing.