On Revolutionary Medicine

Socialized_medicine

 

The life of a single human being is worth a million times more than all the property of the richest man on earth.’ Che Guevara, 1960.

Upon being hit by jet liners in the terrorist attack of 9/11 the Twin Towers of New York City collapsed and turned into rumbles within minutes. Thousands of people were buried inside. Brave American men, fire fighters, first responders along with many civilians volunteered to help, amid lots of smoke, dust and pain.  As a consequence of unprotected exposure to pollutants and trauma, many of those who volunteered developed a variety of respiratory illnesses ranging from pulmonary fibrosis to cancer. Many had psychological terrors like PTSD. When they sought for healthcare in American hospitals, they were denied such, as their insurance did not cover the deliberate exposure of oneself to hazardous conditions. Paying on your own is way too expensive.

As depicted on a documentary called Sicko by Michael Moore, some of these patients sail on speedboats to reach Havana, Cuba, where they receive free checkups, treatment and plenty of medicines to take back home.

Even if we doubt the facts laid by Moore, there is one thing we can all agree upon- though highly sophisticated, the capitalist-styled profitable healthcare system of USA is non universal and thus, a non-existence to many of its own citizens.

Cold war is over. Capitalists have emerged victorious in all but one front- provision of free and high quality essential services to all, like police service for security, emergency responders for fires or any other calamities, health and education. Yes, I deliberately put doctors, teachers, firemen and policemen in the same context, because as much as it is the responsibility of the government for the peace and security of its citizens, it is, for universal health and public education. There can be another discourse on education. This time we talk about health.

Driving around Kathmandu, I see many hoarding boards of private clinics and hospitals. They advertise of services and make promises- like a fairness cream would promise a glow. Such an utter commercialization of health care- it breaks my heart. If you delve in deeper, you can realize the ugliness behind posh medical facade. There are many private hospitals in the city with ‘marketing officers’, whose sole duty is to call ambulance drivers to negotiate commissions for bringing a critically ill patient to them, which is often as high as 4000 rupees. Imagine the size of the bill on discharge.

Poor patients are often denied proper medical care. Every other day some newspaper runs an impromptu piece on how a patient died due to a doctor’s negligence and hospital got vandalized. How government hospitals are understaffed and unclean. And about corruption in purchase of life saving drugs like misoprostol.

But all these examples represent merely the tip of an iceberg. Everything that is wrong with existing health care system is due to chronic lack of vision and planning in making of health care workers, doctors and dispatching them for duty.

 

Making of a doctor

Despite being a profession underpaid and overworked, exploited and allegedly, mundane- our society fancies in their sons and daughters becoming doctors. With dull economy, a medical job might look more secure than other things, so there are many who want to become doctors- which is not bad at all- so many people signing up for a service oriented profession like this. But there’s a catch- we don’t have proper medical education system in our country. We have just one government medical college providing about 40 undergraduate scholarship seats, and rest of the private or semi private institutions serve the desires of aspiring doctors, but in a very high price. It costs at least 4 million to become a MBBS doctor. The prospect is as grim for post graduation studies. Scholarship seats are so few, an aspiring doctor has to either provide his service elsewhere like USA or Australia or pay as high as 10 million or even more to specialize.

Medical education should be free, and to the deserving students. Because the profession is such- where you work really hard through med school and the whole life; where study and work are lifelong priorities; subduing personal comforts or family life; where you skip meals or sleeps for strangers called patients.

The irony is, society expects doctors to invest like a businessmen and serve like a clergyman. It simply cannot happen.

Prof. Dr. Govinda K.C led a fast unto death against such a system, a part of it. Motive behind was to make post graduation scholarships available and of high standards. But despite medical doctors all over the country striking for several days, it could not bring anything tangible. It is because neither our brotherly organization NMA nor governing body NMC has realized impending failure of the system. Or even if they do, they are too happy to complain with the commissions provided by private colleges. But I am not. I worry for the moment when someone in my family gets ill and needs a sophisticated medical care. USA or Singapore or Delhi is beyond everyone’s reach. We have to improve our system and survive here.

 

Where does all the health budget go?

Yes, we do get an ample amount of budget for health care. This covers the salaries of government medical staffs, which they receive for attendance at their institution, and their bhattas which they receive for doing everything else. That is okay, in light of meager salary they obtain for such a hard work (which indeed is, if they work as per norms and needs). But a big chunk of it is wasted through a syndicate of NGO/INGOs with collaboration of health bureaucrats especially during June/July, at the closure of fiscal year- in programs and projects hurriedly planned and carelessly executed. Global Fund provides huge financial support to the government to be spent through partner organizations, and they work- mostly on paper and reports. With most of the aid bearing managerial cost of the projects, they fail to bring any tangible change. To improve overall health of the people, to reach the goal of ‘Health for all’ as we signed in Alma Ata in 1978, all this money should instead be used in establishing a proper health education system in the country, so we can have skilled and willing-to-serve human resource. After all, we cannot depend on foreign aids for the health of our people.

 

How to solve?

A scientific and sufficient health service delivery system, reaching people.

A medical education system to teach, train and produce doctors, nurses and other paramedical staffs.

We have 3600 VDCs in the country. Each VDC has a Health Post, the basic unit of our health organogram. It should have a Health Assistant incharge, with 2 AHWs. Co-existing birthing center should have a staff nurse with 2 ANMs. At next level is a Primary Health Center covering an electoral constituency, which we have 240. Since it provides OPD services to a larger number of and referred cases from Health Posts, in-patient along with 24 hours emergency services, it should have 3 medical officers (doctors) with 2 HA and 5 AHW. Birthing center at this level should have a nurse with Bachelor’s degree, with 2 staff nurses and 5 ANM. PHC will also be overseeing all the community level preventive health programs like immunization, infant care, hygiene etc, rendering NGO led activities redundant. It will be a cost cutting measure in long run.

Each district hospital should be able to treat 80 percent of the cases. After all, it is a health center for the whole district. It should have a double team of consultants (there should be at least two of medicine specialists, gynecologists, surgeons etc) so that one of them can be available all the time; nobody can work 24 hours a day and 365 days a year, thus. It should have a team of 6 medical officers and other paramedical staffs in proportional ratio.

Zonal hospitals should become tertiary centers; teaching hospitals. With ICU, CCU and higher specialists, it should be able to solve 90 percent of the cases. It will have highest flow of the patients, highest concentration of doctors, labs and everything. Since lack of free medical education is a core issue, each of these 14 zonal hospitals will have excellent medical schools, providing 50 scholarship seats for undergraduate studies every year (a total of 700!), to deserving candidates- irrespective of caste, sex, or hometown- but based purely on merit- for we want the best to become doctors and deal with our life and sickness, not the lesser competent.

Such academic centers will not only produce free education to aspiring doctors and nurses but also vacancies for professors- who will now be available at zonal levels. They will mentor post graduate students. With two PG seats in each faculty (including both clinical subjects like medicine, surgery and basic sciences like anatomy, pathology etc)- we will be producing about 30 specialist doctors from every zonal center.  Multiply that with 14 teaching hospitals- we will be providing higher medical education to more than 400 doctors every year, which is a great leap from existing 40. With residents to work round the clock in such hospitals providing meticulous care to patients, service quality will greatly improve and upon graduation they will serve at district hospitals, replacing the consultants who will now become a faculty at zonal teaching hospital. Not only will there be a constant production of medical graduates and specialists, there will be a system of service at all levels, as a clinician and as a teacher- and a timely retirement.

 

With highly sophisticated zonal centers, we would not need the namesake sub regional hospitals. Regional centers will take care of all unsolved cases. Here, professorships will be awarded to consultants, and higher specialization courses will be offered. It will also be the center for skill based trainings and research- where we will invent and devise ideas to revolutionize medical science, provide something to humanity. There will be government pharmaceuticals producing high quality drugs and these medicines will be provided for free- just like medical care would be.

Further, some highly populated districts can have two or three district-level hospitals of equal stratum and formation, each one of them responsible to zonal centers. Big cities can have a couple more; in addition to specialized centers for trauma, heart, kidney etc. But this new plan will discourage people to cluster around cities, since (availability of) health facility is one of the reasons why people migrate.

One might ask, what will be the role of private hospitals and medical colleges, then? They should be graciously thanked for the service they provided when there was none, and asked to seek business elsewhere, for healthcare is not a business and it should be free, for all.

The system as it is, is already a mess and on the verge of a breakdown. If we really want the state of affairs to improve, we- the people, the doctors, the clients, the stake holders should do more than just lament or charity. We need to work on similar plans and preserve to the realisation.

This whole idea might appear audacious to many. I would like to quote Che again, ‘At the risk of seeming ridiculous, let me say that the true revolutionary is guided by a great feelings of love.’

 

Dr. Chirayu Regmi

(who is doing his part at a primary health center in Shrigaun, Dang)

 

 

 

 

 

 

 

 

 

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