A critical appraisal of health care model
TOWARDS A CRITICAL MEDICAL PRACTICE - Reflections on the Dilemmas of Medical Culture Today: Edited by Anand Zachariah, R. Srivatsan, Susie Tharu; Orient Blackswan Pvt. Ltd., 3-6-172, Himayatnagar, Hyderabad-500029. Rs. 495.
To the discerning student of public health, India offers several sets of paradoxes. To name just a few: super speciality hospitals that attract patients from across the world and a large mass of malnourished citizens going without the one ‘medicine' that would cure their ailment — adequately nutritious food; cutting edge technology for diseases like coronary artery disease and the utter neglect of diseases like Kala Azar; and a growing demand for medical courses and no doctors to run the Primary Health Centres (PHCs) and taluk hospitals.
In an attempt to initiate a “dialogue between a self-critical medicine and the new social sciences that offer original perspectives on the crisis,” the book under review uses case histories to map the dimensions of the crisis that engulfs health care. It goes on to analyse the disjunction between “scientificity and efficacy,” “relevance and appropriateness,” and “healing and cure.”
Kala Azar is a forgotten disease peculiar to Bihar, and it affects mostly the rat-hunting Dalits and the marginalised. About a lakh of new cases are reported every year and yet the amount the Central Government spends on combating it is but a small fraction of what it allocates for diseases like AIDS. Anand Zachariah and Srivatsan use this instance to bring out the skewed priorities of the state in tackling diseases, with the ones afflicting the marginalised sections getting short shrift. Many of the doctors today are unaware of U.N. Brahmachari's outstanding efforts in synthesising urea stibamine, a drug used to treat Kala Azar. It was estimated that by 1933 “about 3.25 lakh lives were saved in Assam alone due to urea stibamine therapy.”
In his article, K.S. Jacob cites cases where normal human emotions are medicalised and the individual pathologised. Referring to the societal and institutional responses to such disasters as the Bhopal gas tragedy and riots of the kind that happened in Gujarat, he says the interventions should have been community-based. Instead, the affected persons were branded as suffering from ‘Post-Traumatic Stress' disorder and treated with drugs. His point that “while medicines may be helpful for an individual, when a large section of society is devastated, it is the public health efforts that will empower people to rebuild their lives” is very relevant today. We live in an era where educated parents belonging to the middle class run to a psychiatrist and counsellor even for problems like their children not scoring one hundred per cent in school exams.
Susie Tharu, in “Medicine and Government”, argues that, unlike in Europe, the concept of state's responsibility in health care or ‘health as a right' has never been a part of India's political culture, which is the reason why the vertical health initiatives do little to address the medical needs of the sick at the primary level.
While Sara Bhattacharji feels the PHCs should be much more than vaccination centres, A.P. Ranga Rao narrates his personal experience in dealing with structural problems in developing a comprehensive system of health service in India.
The state of nutrition, rather the lack of it, among the poor in India, is discussed extensively by Veena Shatrugna. She says the chronic hunger prevalent in India today is not due to lack of scientific advances in areas related to food and nutrition. Malnutrition is traceable to faulty policies devised in the 1950s and 1960s. The early onset of diabetes and blood pressure, she says, is a consequence of the wrong policies that believed in the “supremacy of vegetable proteins” to the neglect of others. This chapter is a must read for students of nutrition science.
Zachariah, who speaks of people's struggle producing curative public health for AIDS, wants the advocacy groups to draw lessons from it and apply them in respect of other diseases too.
In their introductory note, the editors of this volume make a critical appraisal of the model of medical education followed in India and argue that its tertiary-care orientation has little relevance to the basic medical needs of a large segment of the population. They advocate an approach that combines “excellence and relevance.”
Overall, the book is a product of intense scholarship. A practising clinician may find some of the chapters rather difficult to comprehend. A simpler language would have made for easier reading. This said, I have no hesitation in commending it to all those involved in building a healthy India.
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