Freedom and Flight

Forcing inexperienced medical students to serve in rural areas against their will is a cop-out.

New Media Fellows 2013

By Anindita Sengupta

August 18, 2013

Also published in the Bangalore Mirror

Once, I knew a boy/man who was studying to be a doctor. When the time came for his mandatory posting in the village as a post-graduate student, he was deeply upset. Brilliant and sullen, he completed his degree with gritted teeth and migrated to the US soon after. His journey reeked of the sort of burning determination that fuels irreversible choices. He lives there now, a neurosurgeon with a wife and kid. He has no intention of coming back. 

There’s no denying that rural areas need doctors. But motivating healthcare workers to take up rural postings is a challenge that requires — and deserves — considerable investment, effort and will

It’s a common enough story, a familiar narrative of opportunity, flight and success, and many ways to respond to it. Desertion, brain drain, the Indian dream — but a myriad moral judgements aside, here is a fact: someone could have been a doctor here but he ended up being a doctor there. 

He may have gone abroad anyway, of course. But I think of it now because the government has decided to make a one-year rural posting mandatory for medical students at the undergraduate level. Doctors around the country are strenuously protesting that the move deflects from other, more serious issues — the lack of infrastructure and medicines, the quality of paramedical staff, even the number of primary health centres. They also argue that the posting makes the already long period of study even longer. 

There are many questions that come to mind. For one, how will this affect the quality of healthcare? 

In an interview in health.india.com, Dr Madhav Deo of the Medical Council of India says: “...let’s not forget that all these UG students will only act as generalists without any insight into specialties. The real problem facing rural India is the lack of specialists.” Merely providing a certain number of doctors is clearly not enough. They need to be skilled. Preferably, they also need to be committed, caring, and passionate about what they do because God knows they’re working with limited tools and resources. Instead, they are recalcitrant and resentful. What are the chances that the quality of healthcare is going to suffer?

Is the government expecting these young men and women — currently organising, protesting and braving water cannons — to tamely become dedicated doctors once they’re in the village?

Some time ago, I wrote about maternal health facilities in Rajasthan for which I spoke to NGO workers there. The problem is not the absence of healthcare facilities, they said, but what goes on inside them. It is not the lack of healthcare workers, but the fact that they are negligent, callous and cruel. We should focus on the reasons for this murky mix of negatives and try to address them. 

Instead, the government abdicates responsibility. We’re still spending too little on public healthcare. Distribution systems for medicines are not in place. We still lacks access to quality generic medicines for heart problems and non-communicable diseases, like diabetes, says a recent report released by University College London (UCL). TB medicines are still out of stock. The poor still hold so much mistrust for public health officials that they travel miles to private practitioners who turn out to be quacks. As Amartya Sen wrote recently, “India may be the world’s largest producer of generic medicine, but its health care system is an unregulated mess.... While China devotes 2.7 per cent of its gross domestic product to government spending on health care, India allots 1.2 per cent.” Pouring young, unskilled and inexperienced people into this problem is not the answer. 

The answer is more complex, more dynamic and more demanding than this. There’s no denying that rural areas need doctors. But motivating healthcare workers to do rural postings is a challenge that requires — and deserves — considerable investment, effort and will. 

A study conducted in Ethiopia and Rwanda in 2009 and available at the WHO website, points out: “A growing body of evidence shows that non-wage job attributes, such as training opportunities, career development prospects, and living and working conditions, play a role in what health workers choose.” It also says that health workers with a rural background are more willing to work in rural posts and more responsive to incentives to work in rural areas. This would imply giving students from rural areas more opportunities from an early age. 

Forcing medical students to serve “time” for short periods, and against their will, is a copout. It’s a haphazard way to make up numbers in this jumbled chaos that we call healthcare. 

It doesn’t require the government to examine human motivation, need or desire. It doesn’t necessitate investment, effort or will. And the ultimate reapers of this rotten seed, the recipients of this quality of care, are ill people with no other choice and nowhere to fly.

Anindita Sengupta is reporting on health in India as a New Media Fellow with the International Reporting Project (IRP).