Heed the patienthttps://indianexpress.com/article/opinion/columns/national-medical-commission-bill-doctors-ima-protests-heed-the-patient-5012042/

Heed the patient

National Medical Commission Bill must address the needs of the consumer rather than the interests of medical practitioners and quacks.

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The nexus between the unqualified practitioners or RMPs (Rural not-Registered medical practitioner) is apparent from the virtual absence of action against thousands of quacks. (Illustration: Subrata Dhar)

The National Medical Commission Bill 2017, well-intentioned and forward-looking, has unfortunately stirred a hornet’s nest. It has brought to the fore a disturbing aspect of an ongoing controversy — the activities of medical lobbies that have persistently thwarted efforts to put consumer interest above their own. Parliament needs to face some unsavoury facts.

Two lobbies are at work backing the professional interests of the allopathic community on the one hand and AYUSH practitioners (mainly ayurveda, unani and homoeopathy physicians) on the other. There are some 10.4 lakh private medical establishments with hospitals accounting for under 8 per cent of them. Most are lone practitioners running small nursing homes and clinics. Most do not possess a medical qualification. A 2016 WHO study has brought out that only 58 per cent of urban doctors had a medical degree and only 19 per cent in rural areas. Only 31.4 per cent of allopathic doctors were educated to the secondary school level and 57.3 per cent did not have any medical qualification. NSSO reports show how barring the metros and large cities, there are more unqualified practitioners than regular doctors.

The interests of all allopathic doctors, regardless of their competence, are looked after by the Indian Medical Association (IMA), a voluntary registered society with state chapters which register doctors as members and lobby with the government, resorting to agitations and strikes whenever doctors’ interests are affected. An all-India membership of over two lakh gives the IMA immense clout so that most chief ministers and even the Union health ministry avoid confrontation.

Many of the IMA’s members are single practitioners and they run their clinics with the assistance of young school dropouts engaged as helpers. They train them to handle acute illnesses and treat acute medical conditions with antibiotics, IV fluids and steroid injections. Once sufficiently skilled, these assistants set up independent practice using the prefix “doctor”. They run a lucrative business charging a fraction of a qualified doctor’s fees. When patients do not respond to treatment, they refer them to a known qualified medical practitioner who remunerates them with a 30 per cent commission.

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The IMA and the Medical Council of India, both at the apex level and in their state units, are aware of what is happening. While their public position is that quackery must be stopped, covertly, both organisations look the other way. The nexus between the unqualified practitioners or RMPs (Rural not-Registered medical practitioner) is apparent from the virtual absence of action against thousands of quacks. The IMA, instead, targets ayurveda, unani and homoeopathy practitioners who hive off their business. Since RMPs are part of the business and generate referrals, action — when taken — is perfunctory.

The National Medical Commission Bill 2017 and for that matter the National Health Policy 2016 overlook this countrywide phenomenon altogether. Under law, the Medical Council of India and the state medical councils are enjoined to take action against those who practise allopathic medicine without being enrolled on the allopathic medical register. As consumer safety is at stake, this is a serious omission from a bill which seeks to replace the medical council.

The practitioners of Indian medicine also constitute another powerful lobby. The National Integrated Medical Association (NIMA) lobbies forcefully in favour of “ integrated practice”. At two national events, the prime minister publicly stated that ayurveda practitioners practise modern medicine and very few use traditional medicine. Even his observation does not seem to have had the required impact.

While the propagation of traditional medicine is publicly pursued with passion, the preponderance of treating with modern medicine is ignored. Authentic ayurveda is now confined to Kerala and western Maharashtra, other than a few government-run universities and colleges in different states. In North India, it is difficult to find even 10 practitioners of pure ayurveda excluding doctors employed by government establishments and colleges.

The development and propagation of the ayurveda system is left to a handful of committed researchers and faculty members in institutions like the Banaras Hindu University, Gujarat Ayurvedic University and Arya Vaidya Sala at Kottakkal and Amrita Vishwa Vidyapeetham in Kerala. The faculty in these institutions is worried. “If AYUSH graduates are allowed to practise allopathy, where does the status and the future of ayurveda stand? They should not be allowed to practise allopathy as otherwise the AYUSH systems will die,” lamented all faculty members I spoke to.

The new Bill must take stock of and address what the country actually needs. The first need is for thousands of community-level accredited practitioners — not full-fledged doctors — who after training should be equipped to provide the first line of care for acute conditions and to make referrals to a regular doctor within a GPS-supervised system. The realisation that neither allopathic nor AYUSH doctors will ever go to lakhs of villages — not even tehsils — must dawn on policymakers. That is precisely why a new system of community-based trained health workers (not government employees) who are enrolled on the state medical register is needed. This can only be done if the medical education law provides for it.

Second, the new Bill should promote integrative medicine enabling people to access multiple choices but available under one roof, particularly for chronic conditions or even as adjuvant therapy. The developed world has recognised that with an increase in life expectancy, chronic diseases, allergic syndromes and rare medical conditions cannot be cured — but the symptoms can be mitigated through traditional medicine. A quest for bridge courses to learn ayurveda has already begun in different countries. The new Bill should recognise the scope for integrative medicine but without mixing medical systems and practitioners.

Citizens are agitated over the mismanagement of both publicly-run and private medical education establishments. The government has done well to bring forward new legislation to replace the medical council. But unless the Bill confronts reality and addresses it, keeping consumer interest paramount, the new law will make little difference to people’s lives. The parliamentary standing committee has an opportunity to make a difference, if it shuns the rhetoric of self-interest professional groups and confronts reality.