Few thoughts on Family Medicine

INTERVIEW: Dr. Sunil Abraham, Dept. of Family Medicine, CMC, Vellore

The government is giving a lot of focus on hospital care, tertiary care and ignoring the primary care.Shahid Akhter  |  ETHealthWorld  |  15 December 2015, 8:58 AM IST

Dr. Sunil Abraham, Dept. of Family Medicine, CMC, Vellore, talks to ETHealthworld about the role and importance of family doctors and how CMC is bridging the healthcare gap between the rural and the urban areas. 

1. Why are we lagging behind in primary care and family medicine? 

There are three reasons. One is the perception problem because the young doctors feel it's not a glamorous specialty. They think that you need to be a cardiologist, nephrologists or a radiologist to have a specialty that is accepted and have some esteem. Second is that people feel you make much more money in other specialties. Third is the policy problem because when we look at countries like the UK, Canada or the Scandinavian countries, they all have a good foundational family medicine. 

You cannot see a specialist without first being seen by your family doctor but this policy hasn't come to India yet. The government is giving a lot of focus on hospital care, tertiary care and ignoring the primary care. These are the reasons why it has not gone forward. 

There have been studies done in other countries. For example; a study done in US found out that in a population of 1000 people, only 1% get admitted in a tertiary teaching hospital. If you increase the duration of medical education in the community, they will learn about the common problems and where problems present to the doctor much earlier in the diseases and that is very important. We have tried doing this in CMC and it is making an impact. 

2. Why and how are the family physicians important? 

There are few issues that people face when they age like multiple diseases. The aged person may have diabetes, hypertension, COPD, muscular skeleton problems, depression, prostate problem etc. They need somebody who can manage all these problems otherwise it is very tedious for them to go from one specialty to another. 

Going to the hospital is becoming more of a harrowing experience because you have to go through the busy traffic, wait in line etc and elderly people may not be healthy enough to do that. They are also looking for people whom they know on continues long time basis. I see a great role of family physicians to give elderly artery care. 

3. How can the healthcare in rural areas be encouraged? 

I personally have worked in a very rural place with 1500 population. I know the realities of working in rural place and how challenging it is. The issues people face are schooling, support system and salary. The infrastructure and the support system in the rural hospitals are very poor. Salary is an issue because they make less money when you are in a rural place. 

Currently from the 50,000 MBBS seats, we have only 10,000 post graduate seats. The government should give a career path for family physicians that are trained to be given consultant post in the rural place and a salary incentive for them. The problem with the community health centers is that you don't have the right kind of doctors. You need more family doctors there who can manage 80-90% of the problems. This will be a solution to increase the healthcare in the rural areas. 

4. What is happening in Family Medicine in CMC? 

We have a department of family medicine for the past 6 years. We are only one of the two medical colleges in the whole country with department of family medicine. Currently we have 10 faculties and most of us work in the four to six bedded unit for the urban poor called the Low Cost Effective Care Unit. 

Some of us work in the urban Ambulatory Care Family Medicine Center where patients are given ambulatory care that means there is no place to get admitted but they can come as a one stop place for most of their medical problems, get the drugs there, give the investigations there and we have minor positions also being done there. 

5. Tell is about the Low Cost Effective Care Unit associated with CMC? 

The main CMC hospital is about 2300 bedded hospital. In 1982, it started a unit called the Low Cost Unit which is 46 bedded hospitals and is 1 kilometer away from the main hospital. Here, when the poor patients come for the first time, they pay 25 Rs as a lifetime registration fees and after that the consultations are free. 

We have 46 beds and all these beds are free. We ask them to pay for the drugs as we don't give out free drugs unless there's an emergency. We manage about 80-90% problems and they have access to all the investigations of the main hospital. 

We have consultants from the main hospital coming to us giving for giving free consultations if we ask them to. We have no other specialists; we have got 5 family medicine specialists and 2 community medicine specialists and few other junior doctors along with all our other staff that runs this space. 

6. How are you associated with Low Cost Effective Care Unit? 

There are two things that I am focused on when I sit in the OPD. One is to see patients of all ages. I manage problems across all disease patterns and all organs. We manage a breath of problems and the other thing is that our focus is not on the disease but on the person. My focus is the person, his issues, how I know him and this relationship is the foundation of family medicine. On a typical day I would see patient with multiple problems and also see people whom I have known for many years. 

Eat Healthy - Beat Diabetes

The World Health Day 2016 is observed worldwide with a theme – Beat Diabetes. Diabetes Mellitus is a chronic, metabolic disease characterized by elevated levels of blood glucose which will over time lead to serious damage to the heart, blood vessels, eyes, kidneys, and nerves. The prevalence of diabetes has been steadily increasing and it has witnessed fourfold increase in the past four decades. About 350 million people have diabetes worldwide, and it is estimated that one tenth of the adults over 18 years have diabetes.
  

Diabetes occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. Insulin, a hormone that regulates blood sugar, gives us the energy that we need to live. If it cannot get into the cells to be burned as energy, sugar builds up to harmful levels in the blood. Hyperglycaemia, or raised blood sugar, is a common effect of uncontrolled diabetes and over time leads to serious damage to many of the body's systems, especially the nerves and blood vessels.

Types of Diabetes 

There are two major forms of diabetes. Type 1 diabetes is characterized by a lack of insulin production and Type 2 diabetes results from the body's ineffective use of insulin. Type 2 accounts for around 90% of all diabetes worldwide. A third type of diabetes is gestational diabetes. This type is occurring or diagnosed during pregnancy. Women with gestational diabetes are at an increased risk of complications during pregnancy and at delivery. They are at increased risk of Type 2 diabetes in the future.

Apart from these three types, IGT (Impaired Glucose Tolerance – high sugar values only after food; not at fasting and IFG (Impaired Fasting Glycaemia – high sugar values only at fasting; not after food) are intermediate conditions in the transition between normality and diabetes. People with IGT or IFG are at high risk of progressing to Type 2 diabetes if appropriate preventive measures are advocated in time. 

Causes

The causes of diabetes are a multiple and complex, but for Type 2 diabetes the increase is in large part due to rapid increases in overweight, including obesity and physical inactivity.  The cause is not known in Type 1 diabetes, but it is thought to be the result of a combination of genetic and environmental factors. Due to this multifactorial feature, diabetes is seldom an isolated entity and usually occurs along with other conditions like Hypertension, Dyslipidemia and Obesity. 

Complications 

Diabetes has become one of the major causes of premature illness and death, mainly through the increased risk of cardiovascular disease and chronic kidney disease. Cardiovascular disease is responsible for between 50% and 80% of deaths in people with diabetes. Lack of awareness about diabetes, combined with irregular treatment, can lead to complications such as blindness, amputation and kidney failure. The life threatening infections, hypo or hyperglycemia are the acute complications of diabetes.

Diabetes is not just a matter of health; its complications bring about substantial economic loss to people with diabetes and their families and to national economies through direct medical costs and loss of work and wages.

Treatment

Early diagnosis and prompt treatment is the cornerstone of diabetes management. Early diagnosis can be accomplished through relatively inexpensive blood testing. Once diagnosed, diabetes needs to be controlled well to prevent further complications. People with type 1 diabetes require insulin; people with type 2 diabetes can be treated with oral medication, but may also require insulin. Other co-morbid conditions and complications also need to be screened periodically and treated appropriately. 

How to Prevent

A large proportion of diabetes cases are preventable. Simple lifestyle measures have been shown to be effective in preventing or delaying the onset of type 2 diabetes. Maintaining normal body weight, engaging in regular physical activity, and eating a healthy diet can reduce the risk of diabetes.
  

To help prevent type 2 diabetes and its complications, one should:

• Achieve and maintain ideal body weight according to the height.

• Be physically active – at least 30 minutes of regular, moderate to intensity activity on at least 5 days in a week.

• Eat a healthy diet of between 3 and 5 servings of fruit and vegetables a day and reduce sugar and saturated fats intake.

• Avoid tobacco use as smoking increases the risk of cardiovascular diseases.

The symptoms of diabetes include excessive excretion of urine, excessive thirst, constant hunger, weight loss, vision changes and fatigue.

If you are in doubt, check! Let’s beat diabetes together!

இங்கு மட்டுமா போலிகள்?

போலிகள் என்றதும் நித்தியானந்தா நினைவில் வருகிறாரா? நான் இங்கு அந்த போலிகளைக் குறித்து சொல்ல வரவில்லை. சமீபத்தில் இந்தியா முழுவதும் பேசப்படும் போலி மருந்துகள் குறித்து தான். இத்தகைய போலி மருந்துகள் இன்று மட்டுமல்ல, காலாகாலமாய் இருந்து கொண்டுதான் இருக்கின்றன. ஆனால் அவை இப்போது அதிகம் பேசப்படுகின்றன.


இந்தியாவில் மட்டுமா இது பிரச்சினை. போலிமருந்துகள் தயாரிப்பு மயங்களும் விற்பனைத் தளங்களும் உலகில் பரவலாக அனைத்து நாடுகளிலும் காணப்படுவதாக புள்ளி விபரங்கள் தெரிவிக்கின்றன. (Source: http://www.who.int/bulletin/volumes/88/4/10-020410/en/index.html)


இத்தகைய போலிகள் மருத்துவத் துறையில் மட்டுமல்ல, அனைத்துத் துறைகளும் தான் என்கிறது, தினமணித் தலையங்கம்: http://www.dinamani.com/edition/story.aspx?SectionName=Editorial%20Articles&artid=209978&SectionID=133&MainSectionID=133&SEO=&Title=%E0%AE%B5%E0%AF%87%E0%AE%B2%E0%AE%BF%E0%AE%AF%E0%AF%88%E0%AE%A4%E0%AF%8D%20%E0%AE%A4%E0%AE%BE%E0%AE%A3%E0%AF%8D%E0%AE%9F%E0%AF%81%E0%AE%AE%E0%AF%8D%20%E0%AE%AA%E0%AF%8B%E0%AE%B2%E0%AE%BF%E0%AE%95%E0%AE%B3%E0%AF%௮


தகவல் அறியும் உரிமச்சட்டம், நுகர்வோர் பாதுகாப்பு அமைப்பு என பல்வேறு நல்ல வழிகாட்டுதல்களின் மத்தியிலும் இவைகள் பெருகக் காரணம் என்ன?

மக்களின் அலட்சியமும் அரசின் மெத்தனப்போக்குமே இத்தகைய போலிகள் மலிந்ததற்குக் காரணம்.

விழித்திட வேண்டியது நாம் - அதற்கு வழிவகுத்து கொடுத்திட வேண்டியது அரசு.

மிஷன் மருத்துவமனைகளை உயிர்ப்பிப்பது எப்படி?

கடந்த 9 ஆண்டுகளாக மிஷன் மருத்துவ மனைகளில் பணிபுரிந்து விட்டு, தற்போது சூழ்நிலைகளின் நிமித்தமாக கடந்த 8 மாதங்களாக தனியார் மருத்துவக் கல்லூரியில் உதவிப் பேராசிரியராக பணிபுரிந்து வருகிறேன். மிஷன் மருத்துவமனைகளைக் காட்டிலும் அதிக சம்பளம் ஆனால் குறைவான பொறுப்புகள்... இருப்பினும் எனது மனமும் இதயத்துடிப்பும் மிஷன் மருத்துவமனைகளின் மீதிருந்து இன்னமும் விடுபட்டுவிடவில்லை.

நான் இது குறித்து சிந்தித்துக் கொண்டிருக்கும் போது, ஜாமக்காரன் பத்திரிக்கையில் வாசித்த சேலம் பெத்தேல் மருத்துவமனையைக் குறித்த செய்தி இதுபற்றிய சிந்தனையை இன்னமும் தூண்டிவிடுவதாக இருந்தது.

அதனை இங்கே http://www.jamakaran.com/tam/2009/december/bethel_hospital.htm படித்து, மிஷன் மருத்துவமனைகளை உயிர்ப்பிக்கும் பணிக்கு தங்களின் மேலான அலோசனைகளை இங்கே பதிவிடலாமே!

நவம்பர் 14 - உலக சர்க்கரை நோய் தினம்

வருடந்தோறும் நவம்பர் 14 என்றாலே, நமக்கு நினைவிற்கு வருவதெல்லாம், குழந்தைகள் தினம் தான். உலகில் பல்வேறு தினங்களில் இது அனுசசரிக்கப்படுகையில், இந்தியாவில் குழந்தைகள் மீது பரிவு கொண்ட நேருவின் பிறந்த தினமான நவம்பர் 14 - குழந்தைகள் தினமாக அனுசரிக்கப்பட்டு வருகிறது. அதுவே குழந்தைகள் தினம் வெகுவிமரிசையாக அனுசரிக்கப்பட காரணம் என்றால், அது மிகையல்ல.


ஒரு தலைமுறை போய், அடுத்த தலைமுறையில் பலவிசயங்கள் மறக்கப்படும் நிலை போன்று, விரைவிலேயே முக்கியத்துவம் குறைந்த நாளாக மாறப்போவதில் ஒன்று இந்த குழந்தைகல் தினம். காரணம், நேரு பழையவராய் ஆகிவருவதாலோ, குழந்தைகளெல்லாம் முன்னேறி வருவதாலோ அல்ல... காரணம், உலக அளவில் முக்கியமான நாளாக வேகமாக உருவெடுத்து வரும் உலக சர்க்கரை நோய் தினமே ஆகும்.


சர்க்கரை நோயைக் கட்டுக்குள் வைக்க உதவும் இன்சுலினைக் கண்டுபிடித்த ’பிரெட்ரிக் பேண்டிங்’ என்பவரின் பிறந்த நாளான நவம்பர் 14, உலக சுகாதார நிறுவனம் மற்றும் உலக சர்க்கரை நோய் கழகத்தினால் 1991 முதல் உலக சர்க்கரை நோய் தினமாக அனுசரிக்கப்பட பரிந்துரைக்கப் பட்டது. 2007 முதல் ஐக்கிய நாடுகள் சபையும் இதனை அங்கீகரித்து இதற்கு உத்வேகம் கொடுத்து வருகிறது.


அடுத்த நான்கு வருடங்களுக்கு (2009-2013) இத்தினத்தின் மையக்கருத்து , “சர்க்கரை நோய்க்கல்வி மற்றும் தடுப்பு”. உலகில் (குறிப்பாக இந்தியா போன்ற வளரும் நாடுகளிலும்) வேகமாக பெருகி நம்மை மிரள வைக்கும் சர்க்கரை நோய் பற்றி, மேலும் அறிந்து கொள்ள:

http://www.worlddiabetesday.org/

http://www.idf.org/

அது என்னங்க "Community Medicine"?

என்னோடு நெருங்கிப் பழகும் பலரும், ஏதோவொரு கட்டத்தில் என்னிடம் கேட்கும் கேள்விகளில் ஒன்று, அது என்ன.. MD - கம்யூனிட்டி மெடிசின் என்பது.... MD என்றாலே General Medicine என்று தான் நினைக்கிறோம். அப்படின்ன்னா நீங்க மத்த MD மாதிரி practice பண்ணலாமா? என்பது போன்ற பல கேள்விகள்....


இது பற்றி சராசரி மருத்துவர்களுக்கே சரியான விபரங்கள் தெரியாது என்பது வெட்கத்துடன் ஒத்துக்கொள்ள வேண்டிய விஷயம். அவர்களுக்கே தெரியாத விஷயம் நமக்கெதற்கு என நீங்க நினைக்க மாட்டீங்கண்னு நான் நம்புறேன்.

அதனால, உங்களுக்காக இதோ ஒரு இணைப்பு: http://www.iapsm.org.in/medicine.htm

What is Community Medicine?

The study of health and disease in the population of defined communities or groups in order to identify their health needs,
and to plan, implement, and evaluate health programs to effectively meet these needs.


What are the Goals of Community Medicine?


Protection & Promotion of Public Health.



How Community Medicine differs from other branches of Medicine?

Community Medicine reaches out to people to provide services for prevention of disease (such as immunization, pre-natal care, health screening etc.), promotion of health (such as safe water supply and sanitation, vector control measures, tobacco control policy etc.) and provision of primary medical care (treatment of common ailments such as diarrhea, pneumonia, TB, leprosy, malaria, hypertension etc.) whereas other branches of medicine largely provide diagnostic and treatment services to patients who seek treatment.


Is Community Medicine different from Public Health?


In India Community Medicine is synonymous with what is known as Public Health Medicine or Public Health in other countries.


Who are Community Medicine Specialists?


Medical doctors who have done MBBS and a three year Doctor of Medicine (MD) course in Community Medicine during which they are trained in

Epidemiology and Bio-statistics
Health Planning and Health Management
Health Education and Health Promotion
primary Medical care


Community Medicine Specialist is a Five Star Doctor:

Epidemiologist
Health Manager
Health Advocate
Health Communicator
Family Physician

A Community Medicine Specialist

Has in-depth understanding of the determinants of health and diseases.

Diagnoses and manages common illnesses and emergencies encountered in the community.

Adopts integrated approach to develop policies to meet the health needs of the individual, family and the community.

Conducts epidemiological investigations of communicable and non­-communicable diseases and suggests appropriate solutions to public health problems.

Conducts investigations into the problems of health services of the community.

Plans, organizes, implements and evaluates health services and health programs.

Interprets records and reports of health services at various levels of health care delivery system.

Performs research and applies research findings to improve health services of the community.

Undertakes teaching and training assignments in the field of community medicine for various categories of medical
and paramedical personnel.

functions as an effective member as well as a leader of the health team.




Career Options for Community Medicine Specialist:



Epidemiologist in Health Services or in Research Organizations

Public Health Officer in State or Central Health Services

Public Health Project Manager in UN & other NGOs

Research Officer in Medical Research Organizations & Pharmaceutical Industries

Family Physician in Health Care or Health Maintenance Organizations

Teacher in Medical Colleges & Public Health Schools


இப்போது கொஞ்சம் புரிந்து கொண்டீர்கள் என நினைக்கிறேன். காலம் மாறமாற எங்கள் பங்கும் மாறிக் கொண்டே தான் இருக்கிறது. Community Medicine என்ற வார்த்தை கூட, பல்வேறு மாற்றங்களுக்குப் பின்னர், இப்போது 15 வருடங்களாகத் தான் வழக்கத்தில் இருக்கிறது.


மாறிவரும் சமுதாய சூழ்நிலைகளுக்கு ஏற்ப, எங்கள் பங்கினை முழுவதும் வழங்கிட நாங்கள் ரெடி... எங்களை புரிந்து கொள்ள நீங்க ரெடியா?



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Needed: ‘basic’ doctors of modern medicine

(Meenakshi Gautham K,M. Shyamprasad)


India is the largest supplier of foreign medical graduates to the United States and the United Kingdom. Yet, its own rural areas have remained chronically deprived of professional doctors. The historical antecedents of these shortages could be traced to a landmark health policy document, the Bhore Committee Report of 1946. That report constructed the concept of a ‘basic’ doctor as one trained through five-and-a-half years of university education. An alternative cadre of Licentiates who were trained over a shorter duration and who formed two-thirds of the country’s medical practitioners then, was abolished, in spite of strong dissent from several members of the committee. These dissenting comments must be revisited in the context of India’s persistently poor health indices and inadequate health services for the majority.

The report

In October 1943, the Government of British India appointed the committee to survey the state of public health in the country, and make recommendations for future development. The committee chaired by Sir Joseph Bhore, a senior civil servant, comprised eight British and 16 Indian members. The Bhore Committee Report, published in 1946, was meticulously drafted and reflected its members’ profound understanding of health matters. They presented statistics on the disease burden and attributed the poor state of health in the country not only to inadequacies in medical services and health personnel but also to the prevailing social ills — poverty, illiteracy, poor nutrition and unsanitary conditions.

The report is best known for providing the blueprint for a modern public health delivery system in India, along with the training of its personnel. Foremost among these was the ‘basic’ doctor of modern medicine who would be central to the delivery of primary healthcare. These were far- reaching recommendations and shaped the course of public health and medicine in independent India. But on closer examination, a number of flaws are revealed.

Two classes

There were two classes of medical practitioners of Western medicine at the time of the Bhore survey: graduates who underwent a five-and-a-half-year course in the medical colleges, and Licentiates (LMPs) who underwent a three-to-four-year course in medical schools. Of the 47,524 registered medical practitioners at that time, nearly two-thirds (29,870) were Licentiates and one- third (17,654) were graduates.

The report informs us that in the rural areas health care was delivered through sub-divisional hospitals and dispensaries that were managed mostly by Licentiates. Besides, there were large numbers of indigenous practitioners providing affordable and accessible healthcare to the masses.

The Bhore Committee proposed a three-tier district health scheme. A primary unit would be at its periphery, a secondary unit at the sub-divisional headquarters would provide more specialised services, and a district organisation would be in charge of the overall supervision of district-level health activities.

Though conceptually well-organised, the scheme was designed to cover only a fourth of the population in the first five years (78,080,000 out of a projected 315 million in the report) and less than half (156,200,000 out of a projected 337.5 million) over the next 10 years. The report was silent on how the needs of the rest of the country would be met.

Nonetheless, the committee recommended that the Licentiate qualification be abolished, all medical schools be upgraded to colleges, and all available resources be directed into the production of only one type of doctor. He or she would have the highest level of training — a five-and-a-half-year university training, similar to what the Goodenough Committee had proposed for Great Britain as the gold standard. The committee believed that there was no role in the modern medical scheme for indigenous systems of medicine and its practitioners: these systems were considered “static in conception and practice.”

Six members of the committee, five Indians and one Briton, put up a brave dissent. They repeatedly argued that in view of the manpower shortages, the country should use every possible means, including the shorter Licentiate course, to increase the number of trained medical personnel. They pointed out that England had abolished Licentiate teaching only after 100 years and Russia relied extensively on ‘feldshers’ (medical assistants) to run 48,000 dispensaries. They noted with anguish that since the new scheme would benefit only a section of the Indian population, “Public health over the remaining four fifth to one-half of the country… will atrophy. There will be no personnel like the licentiates even to help the regions and institutions which will come under neglect.”


Prophetic

The dissenters’ views proved prophetic. They said that the “basic doctor would not willingly fit into the rural scheme.” India’s six decades of chronic shortages of doctors in the rural areas are grim testimony to this fact. They argued that “while a majority on the committee can abolish the licentiate, they cannot prevent other practitioners, practising a variety of systems of medicine, taking his place.” Time has proved this also to be a prescient observation. Studies show that since Independence and even today, much of health care at first contact in rural India is delivered not by qualified doctors but by informally trained and unlicensed private practitioners.

What happened to the highly trained basic doctor of the future?

The Bhore Committee estimated that around 15,000 doctors would be needed in the scheme in the first five years, and around 30,000 over 10 years. As the number of medical colleges roughly doubled during this period (from 19 in 1946 to 42 in 1956) it can be estimated that the number of graduates also doubled.

It is difficult to obtain exact data on how many graduates entered the health system over 10 years, but almost all of India’s Five-Year Plans and national health policies since 1947 have lamented the shortage of doctors in the rural areas.

What is definitely known is that around 10 years later, in the early 1960s, nearly 18,000 graduate doctors from the Indian sub-continent migrated to the U.K. in response to Health Minister Enoch Powell’s call to save the U.K.’s rapidly expanding National Health Service (NHS) from a staffing crisis. In November 2003, a BBC documentary “From the Raj to the Rhondda: How Asian Doctors Saved the NHS,” acknowledged the contributions of doctors from the Indian sub-continent to Britain’s most deprived areas, where no British doctor was willing to go.

Even today, the second largest proportion of doctors registered with the U.K.’s General Medical Council, by country of qualification, is from India: they number 25,720, or 11 per cent of the total. India also provides the largest pool of international medical graduates to the U.S.

Turf protection

Medical historians point out that the Indian doctors who collaborated with colonial rule were the ones who stepped into positions of power after 1947. Their socialisation into the western model meant that the “development of medical practice in India did not follow the pattern that was being advocated for developing countries at the time. Indian degrees were quite suitable for working in England, but probably totally irrelevant for working to the benefit of the vast majority of the Indian population.” (Professor Aneez Esmail, 2007)

Ironically, even less-trained providers can efficiently deliver primary care. However, efforts to revive a Licentiate type of cadre, as recommended by the National Health Policy 2002 and outlined by a Task Force on Medical Education in 2007, have been non-starters. This is due to resistance from a section of the country’s medical fraternity which carries a turf protection mindset, supported by obstructive legislation contained in the Indian Medical Council Act of 1956.

An alternative

In view of the obvious deficiencies in India’s overall rural infrastructure, it is unlikely that the rural areas will have a sufficient number of doctors over the next several decades. Thus, the solution to India’s doctor shortages does not lie in building more medical colleges. A better alternative would be to draw from other countries’ experiences of developing mid-level practitioners: Clinical Officers and Medical Assistants in Africa, Physician Assistants in the U.S., Nurse Practitioners in Canada, and the rural doctors in China who number more than a million. These cadres are typically trained for three years and empowered to provide clinical services. Studies so far suggest that their performance and outcomes are in no way inferior to that of doctors trained for longer periods.

In the short term, India must also upgrade the skills of existing unlicensed rural practitioners and empower government nurses and pharmacists to take on additional tasks. An alternative to the IMC Act is the Drugs and Cosmetics Act that empowers States to recognise practitioners other than MBBS-holders to provide a limited range of medical care services. Chhattisgarh has invoked this power to create a three-year diploma course for Practitioners of Modern and Holistic Medicine.

(Meenakshi Gautham, PhD, is a public health specialist ( gautham.meenakshi@gmail.com);K. M. Shyamprasad, M.Ch., FRCS, is a former vice president of the National Board of Examinations, MoHFW, India ( shyamprasad@nlhmb.in). Legal inputs have been received from Indira Unninayar, Supreme Court Advocate.)



http://beta.thehindu.com/opinion/lead/article43383.ece?homepage=trueabove accessed on 6 November 2009

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