The Jan Swasthya Sahyog hospital in Ganiyari, in Chhattisgarh’s Bilaspur district, has 62 permanently over-subscribed beds, an operating theatre, a laboratory and a pharmacy, all spread across a low-rise complex. Its outpatient clinics see over 300 people a day, from a catchment area the JSS calculates as taking in over a million people. Besides the hospital, the JSS, a non-profit rural health organisation, also trains community health workers and runs mobile clinics. The demand for its services is immense. Bilaspur, according to the 2011 census, has a population of 2 million people served by only 60 doctors, and over half of its 1,566 villages have no medical facilities whatsoever. The average wait for an appointment at Ganiyari is between five and seven days, during which patients and their families cook on the roadside outside the complex, and, if they can find space, sleep in the organisation’s dharmashala.
I visited the hospital, located a three-hour drive north from Raipur, in April, and was shown around by Dr Yogesh Jain, one of the JSS’s founders. Despite the hospital’s heavy caseload, the atmosphere was calm. Patients hid from the sun in the shade of wide verandas, or beneath flowering bamboo in the complex’s central compound. “I know,” Jain told me on my first morning. “The fire doesn’t feel like a fire.”
Every day, the JSS confronts some of the most critical clinical and logistical problems in Indian public health. Key among them is a chronic shortage of doctors. The country’s doctor-to-patient ratio stands at 0.7 per 1,000, while the World Health Organisation’s recommended minimum is 1 per 1,000. In rural India, the ratio is far worse: figures from the Central Bureau of Health Intelligence show that the 68 percent of India’s population living outside its cities is attended to by only 33 percent of the country’s doctors.
One part of the rural problem is a shortage of specialists: doctors with advanced training in a particular field of medicine, such as oncology or cardiology, and who require the kind of hi-tech medical infrastructure rarely available outside urban areas. The ministry of health recently reported that 83 percent of specialist posts in rural places currently lie empty. That statistic was widely cited and lamented in the press, but, Jain told me, “to cry only about the shortage of specialists is misplaced and unjustified,” and overlooks another crucial lack. The JSS could easily use another 20 specialists, he said, but the more pressing need here, and across India, is for well-trained family physicians.
Family physicians are medical generalists, and ideally stand on the front lines of public healthcare. They can treat a wide variety of illnesses, diagnose serious conditions in their early stages, and refer patients to specialists if appropriate. An adequate corps of family physicians—also colloquially known as general practitioners, or GPs—can significantly reduce pressure on the medical system, reducing the numbers of people requiring hospitalisation or specialised care. These physicians also help optimise the use of resources, by making sure that specialists—who require longer and more expensive training—need only treat patients with a demonstrable need for their expertise. In the 2002 National Health Policy, the latest such document (a new policy is currently in draft form), the government acknowledges that “in any developing country with inadequate availability of health services, the requirement of expertise in the areas of ‘public health’ and ‘family medicine’ is markedly more than the expertise required for other clinical specialties.” India, that document says, suffers from an “acute shortage” of trained personnel in both those disciplines.
Especially in rural settings, with their diverse medical problems, family physicians are often the best-equipped doctors to provide effective treatment. Jain compared them to the late Bollywood star Kishore Kumar. “He was a singer, an actor, a lyricist, a director,” he explained in a small consulting room in Ganiyari, as he worked through a nine-hour clinic for outpatients. “We need fewer specialists and more Kishore Kumars.”
Aside from a rare few, Jain explained, specialists “have unlearnt everything except their own specialty.” He gestured through the open door towards the crowded waiting room. “And you can’t pick and choose from this sea of need.” The JSS has nine senior and five trainee doctors on its permanent staff, including specialists in paediatrics, surgery, obstetrics and anaesthesia. Jain was trained as a paediatric oncologist, but he described himself, and his specialist colleagues, as being in a constant state of “de-specialising.” “We have had to become specialists in generalism,” he said, “in order to provide the most comprehensive care possible.” He told me the JSS needs at least four more family physicians on its permanent staff.
That need is unlikely to be met anytime soon. There is no comprehensive count of the number of family physicians practising in India, but indications are that the country’s medical students are being influenced by a systemic bias towards narrow specialisation—and hence urban practice—to the detriment of family medicine.
At all medical institutes, aspiring doctors begin with an undergraduate medical course—the MBBS—typically completed in five and a half years, which qualifies them to begin basic practice. Most hope to also complete a postgraduate degree as a specialist in a particular field—of which family medicine is one. Many specialists then go on to pursue super-specialty courses focused on certain aspects of their field. In India, MBBS graduates compete fiercely for about 25,000 postgraduate seats available across the country every year. Dr Raman Kumar, the president of the Academy of Family Physicians of India, told me via email in October that of these, only two are for degrees in family medicine, both at Calicut’s Government Medical College. The only other path to a qualification for students interested in family medicine is to pursue one of the 200 diplomas in the field available each year through courses administered by the National Board of Examinations. This takes two years, and predominantly involves correspondence courses for MBBS doctors wishing to enhance their practice.
I found evidence of a heavy bias towards specialisation over a year of research at Delhi’s All India Institute of Medical Sciences—India’s premier medical institute, with a mandate to set standards for medical education across the country. “AIIMS killed the GP,” a former director of the institute told me in May last year. (To encourage candid views, I promised anonymity to all the current and former AIIMS faculty and administrators I interviewed.) The former director claimed the institute has sidelined family medicine ever since its inception in 1956. Today, it bears part of the consequences. Though AIIMS is officially a public teaching hospital of specialised, tertiary medicine, every day it treats scores of patients with conditions that have escalated due to neglect or inadequate primary treatment—the very things family physicians help prevent. Hundreds of desperate patients—many from rural north India—sleep on the streets outside AIIMS every night, waiting their turn for attention. Exposure to patients requiring all levels of care is an educational asset for AIIMS’s students, the former director said, but the institute does not encourage students to become generalists in the long run. A current senior faculty member told me that AIIMS “takes more pride in results of the USMLE”—an exam for postgraduate study in the United States—than in who among its graduates “goes to work in a primary health centre.”
“MBBS is considered nothing here,” a fourth-year undergraduate student, who asked to remain nameless, explained. “You are not considered a good doctor if you have only an MBBS degree. You are supposed to do PG”—postgraduate study—”and then after that super-specialisation.” Agam Jain, from the same year, agreed. “It’s becoming a trend that super-specialty is everything,” he told me. “Without super-specialty we can’t do anything.” A senior surgical resident at the institute told me that this is partly a response to the prevailing public view of medicine in cities such as Delhi. “Everyone wants to come to a super-specialist,” he said. “If they have a headache, yes, let’s consult a neurologist. For chest pain, you consult a cardiologist.”
Among the 25 MBBS students I spoke to, rural practice was defined by a lack of infrastructure, and the treatment of relatively simple conditions such as colds and diarrhoea. As such, they considered it unworthy of doctors with an AIIMS education. “If you go to a peripheral centre,” Agam Jain said, “you will be seeing mostly cases which won’t utilise all the knowledge you have. We are given so much knowledge in these five years … plus maybe three years of postgraduate training. A person with so much knowledge, why would he want to waste all this effort he has put in? He will be able to do nothing, write paracetamol or something for everyone.”
The preference for specialisation is neither unexpected nor unwarranted with today’s rapid expansion of medical knowledge. India, just as any other country, needs specialists, particularly as it confronts a growing burden of non-communicable diseases. But AIIMS, I found, emphasises specialised expertise without addressing the implications this has for Indian healthcare as a whole, or how it might restrict students’ choices. As Saloni Kapoor, another fourth-year MBBS student, put it, “Even if we were interested in family medicine, we wouldn’t know, because we aren’t exposed to it.”
So far, the government has taken only cursory steps to correct the imbalance. The 2002 National Health Policy envisaged “the progressive implementation of mandatory norms to raise the proportion of postgraduate seats” in family medicine, and also in public health, “to reach a stage wherein 1⁄4th of the seats are earmarked for these disciplines.” But the numbers Kumar shared show that the critical shortage of seats in family health remains. In 2012, the government opened six new AIIMS across India, with each, unlike the original in Delhi, housing a department of community and family medicine. However, according to Kumar, no family physicians have been recruited to faculty positions at the new institutes, so these departments remain dominated by public health practitioners without clinical expertise in family medicine.
At Ganiyari, Jain was emphatic about the need to explode misconceptions about rural practice. He dismissed the idea that the needs of rural people are less complex than those of city dwellers. If anything, he said, they are made more so by the extreme poverty and malnutrition that both provoke and intensify medical problems. This, in turn, translates into challenging and stimulating work for doctors. Part of the JSS’s myth-busting involves making use of modern technology. The Ganiyari hospital has a custom-built hospital management and information system that, among other things, lets doctors use iPads to view patient records and test reports, or pull up the latest medical research to inform decisions. Doctors at the JSS also regularly consult colleagues over the internet, including doctors from the United States and some at AIIMS.
The JSS has close ties to the institute: five of its ten founders were trained at AIIMS, and Jain once taught there. Several current AIIMS faculty members regularly travel to Ganiyari, on personal leave, to volunteer. But despite persistent efforts to establish an official link with the institute, which could expose both its faculty and students to the potential of fulfilling rural practice, AIIMS has thus far proved reluctant, according to two senior faculty members in Delhi.
On my second day at the hospital, over lunch at the staff mess, I met Pankaj Tiwari, a junior doctor who had been in Ganiyari for eight months. Of his MBBS batch at a medical college in Delhi, he said, he was the only one pursuing rural practice. He felt he had “learned the lives of patients” here, by developing relationships with them and being invited into their homes. “I have an anthropological, economic and medical perspective now,” he said. When I checked in with him in October, Tiwari was still practising in Ganiyari, and pursuing a distance-learning diploma in family medicine through the Christian Medical College in Vellore. The narrow focus of specialisation did not appeal to him. “A specialist never becomes, or he forgets how to be, a complete doctor,” he said.