Even so, 95% of graduates return to an urban practice or hospital

Sevagram, Service Village in Hindi, is a village 12 hours away from Jamkhed. The village served as Gandhi’s ashram beginning in 1936 and also plays host to the Mahatma Gandhi Institute of Medical Science, where I visited after Kanha to learn about the Department of Community Medicine. The department is doing great work on two fronts: first in motivating and encouraging medical students to practice in more rural areas, not only by force but also inspiration, and second by working to build the capacity of the village through CRHP-similar methods. Both these endeavors breathe of Gandhi’s hope for India, and even more his message for Sevagram. In 1945 Gandhi asked Dr. Sushila Nayar to begin a clinic for small infants and women in the village, in hopes of training village health workers and empowering the common Indian village to deal with the core health problems disproportionately affecting the rural population.

The reality is that India graduates roughly 30,000 doctors per year¹ yet hardly any can be found practicing in rural areas, all choosing urban centers instead. To try to curb this trend, the government has set up primary health centers for every 100 villages, creating an auxiliary nurse midwife to provide immunizations and monitor pregnant women, and instituting village-level traditional birth attendants for deliveries not done in the hospital. While this has created more jobs and more locally-available health staff, the effects have hardly been felt. A 2003 study in rural Maharashtra showed that only 12% of pregnant women receive the minimum antenatal care package, even though this is a service provided by the ANM.

To address the inequity in infant mortality and disease transmission, doctors are needed in the rural areas. Doctors are needed where health status is at its most fragile – in the rural village, not in a private practice in Pune. Doctors are needed where the majority of patients are, not where they could travel to, forcing them to miss work and pay unaffordable fees.

The success of CRHP empowering illiterate village women to reduce the prevalence of disease and sickness in their community has been made possible by the low-cost and supportive secondary-care hospital at CRHP Jamkhed that the village health workers can refer to. Without the hospital, patients would have to be referred to the district level hospital one and a half hours away and at times 2-3 times the cost for the same operation (for example–delivering via cesarean at the district hospital: 15,000 rupees or $300. At CRHP’s hospital: 5,000 rupees).

Even with VHWs, ANMs and TBAs, doctors are needed in rural areas to provide the necessary secondary and tertiary care that untrained professionals are not able to care for. Presently, when villagers have serious health problems, there seem to be three options: either they miss work and visit a hospital, they ignore the problem in the hope that it goes away, or they visit a traditional healer or village-level medical provider with no medical training who tends to give antibiotic injections for every complaint. There is little room for easy decisions and every choice has bad implications.

The department of community medicine has responded to this need by instituting programs to orient the students and provide them with a personal experience of rural life. Immediately after admission to MGIMS, first-years have an orientation in Gandhi Ashram for 15 days. Further, all first-years have to live with a family in a village for 15 days to carry out health, sanitation and nutrition surveys, returning each subsequent year for follow up. Finally, since 1992, it has been made mandatory that after medical school, new graduates serve for two years in rural villages, working with Institute-approved NGOs or in a government rural health center.

As I spoke with med students at MGIMS, I asked them what their plans were after graduating and completing their two-year rural fellowship. The first year students expressed their interest in staying rural and practicing medicine in the village. Answers from fourth and fifth year students: two wanted to be orthopedic surgeons, one an optometrist, and practically all said they planned to live in an urban setting. The attraction for doctors to urban life is just too great. If they are originally from an urban area, than they are practically foreigners to village life. If they are originally from a rural area, becoming a doctor is viewed as their way out. Being a doctor in an urban area pays more, as the patients tend to be wealthier and the problems more specialized. Plus, for their family, money is important, as they can now put their children into a private school and “give them a better future,” as one student put it.

Dr. Garg, head of the department, admitted that there is little in the village that attracts doctors to practice there. The education system tends to be worse and the government has set up no incentives to bring doctors away from urban life and into the village. Plus, as an outsider to the village, the doctor has to either find a house (difficult in a small village) or build one (which he/she tends to have little interest in doing). Perhaps the government should set up housing for doctors and compensate them to live in more rural settings? At what cost, though, must you motivate the physician to practice morality and equity? Whatever the solution, it must be accompanied by a change in the mindset of the physician to view medicine not as a lucrative profession but as the opportunity to meet the needs of the sick and enable the village to become healthy and productive.

Dr. Bang from SEARCH-Gadchiroli put it well when he told the story of Akbar and Birbal:

Akbar asks Birbal to find the ten most foolish men from his kingdom.

Birbal went yet was able to find only nine foolish persons; finding the tenth one was becoming a difficult task.

In his search for the tenth fool, he was walking up and down the road of Delhi. The road was in darkness except for a beam of light falling out from a window of a house. A man was bending and seemed to be searching for something. Birbal approached and asked him what he was searching for.

“I have lost my diamond ring and I am searching for it, and am not able to find it.”

“I can see that you are not able to find it. Where did you lose it?”

“In the forest, on the other bank of the Yamuna River.”

“Then, go and search there.”

“There is darkness there, while here there is light.”

The ring was lost in a forest, but it was being searched on a road of Delhi. Birbal found the tenth fool.

Dr. Bang followed by saying – unluckily, most of our medical research is done in this way. Health is lost in the villages but the research is done in the city, where there is light, facilities, air-conditioned rooms, but there are no problems.

Happy Hannukah! Merry Christmas! And a very happy new years!