The Tower of Babel: Are Indian doctors in the Health Ministry’s Crosshairs?

First, it was at the Mint. Then, I caught it at India Ink with an error to boot. Then, a war of opinions started on Twitter. All of it a big storm in a tiny teacup.

The Indian Government (GOI), through its Minister of Health Mr. Ghulam Nabi Azad, announced yesterday that, from this year on, Indian doctors who planned to pursue medical training in the US would first need to sign a government bond that would enforce their return to India upon the completion of the training period. The minister said that this initiative was a reactionary response to a specific US demand that Indian doctors must be in possession of an NOC (No Objection Certificate) from GOI. He further stated, that non-compliance would force GOI to revoke the NOC which action, would automatically prevent the doctor from practicing his trade in the US.

The glaring logical and legal gaps in this position are stark enough to have given the matter a quiet burial. Instead, what followed was a flurry of writing and debate in both mainstream and social media. In the ensuing cacophony of interpretations and assumptions whatever little was understood, of government-speak, was further mangled. It is perplexing that a simple clarification of the issues (from doctors) and of the statement (from the ministry) was not sought. In the absence of such an explanation and because the subject of medical education and licensing is frustratingly complicated (worldwide), a detailing of some of the underlying issues seems necessary.

The degree:

India: Indians, upon graduation from med school, are conferred an MBBS. After this basic degree, an additional three year training in a specific subject, confers on them an MD/MS. Beyond this there are two year courses, referred to as super/hyper-specialization programs, which confer the DM/MCh degrees. All these degrees can only be obtained after training in a medical college. Since the demand for any of the post-MBBS degrees is huge, GOI set up the National Board which confers the DNB degrees. These are ‘MD equivalence’ degrees, that are offered by ‘private hospitals’ (not medical colleges) under the aegis of the Universities.

US: The basic medical degree is itself an MD. An MD therefore is typically equivalent to an MBBS. The difference: All MDs in the US are guaranteed training in a specialty of their choice. The demand-supply is perfectly met with a deficit on the ‘demand’ side (demand here refers to the market need for doctors), which provides the portal of entry for foreign medical graduates (FMGs). This training is called a Residency and is equivalent to the Indian MD. Onl,y that it confers no degree. It is important to note that since FMGs are only needed by the US to fill the market demand as and when it crops up; FMG intake is subject to capricious movements of US policy.

Mr. Azad’s target group:

The Indian doctor with an MBBS or MD, who wants to train in a US residency program. Not students who go to medical school in the US. The India Ink article(linked above), erred in reporting this. It must needs be highlighted, that the Minister makes no distinction between graduates of government medical colleges (subsidized fee structure paid for by the public) and private medical colleges (higher tuitions paid for by the student alone).

THE ISSUES:

1. Is this stipulation specifically for US bound doctors only?

Yes. The GOI initiative stems from a US demand for an NOC. Doctors who wish to study in Australia, UK, NZ, Russia, China – anyplace but the US – are not subject to this rule.

2. Can the GOI be blamed for this policy initiative?

Not really. Since they clarify that the need for the NOC initiated from the US. Having said that; it is impossible to ignore GOI’s ill concealed schadenfraude at the possibility of waving the Damocletian threat of ‘retracting the NOC with subsequent denial of a US work permit’ if a doctor fails to comply.

3. Is the GOI justified in expecting doctors to return?

Yes. But, only the return of those doctors whose medical education it paid for. To elaborate and in all fairness, GOI has a legitimate expectation in demanding a return on its investment. The cost to the government for training doctors to serve society is enormous. Government medical students get excellent training for a pittance. For those that protest the use of that adjective: this is a good time to remind yourselves that a lot of medical training is clinical exposure to patients. And government hospitals afford an unmatched breadth of experience in this regard. A more demanding public would have insisted on a return on their tax Rupees long back. Socialism is not a one way street. A student who has availed of the government subsidy to finance his education cannot have a reasonable objection if the government expects him to serve (for a limited time period) the society that paid for his education. This reasoning will not be lost on ‘more progressive’ societies, such as the US, where discussions abound on issues of far lesser import, for e.g., on whether people who rely on food stamps can exercise the right to buy food of their choice. Or on where insurance companies can pay based on pre-conditions.

4. Is it a bond? Is it an affidavit without a bond?

I don’t know. The minister did use the word ‘ bond’. Bonds usually have conditional guarantees on freedom. Such as, a fine. Or community service for a period. In any case, why is there so much hyper-reaction to a bond, when many missionary medical institutions such as St. John’s in Bangalore and CMC in Vellore already have such conditional enforcement. And btw, yes, you can buy your freedom too.

5. Did the GOI or MOH say that this initiative was aimed at reversing a ‘brain-drain’ or at leveling the demand for doctors?

NO. This is simply the interpretation of the media. And a wrong one at that! It is obvious to anyone (and that is *anyone), working in health and allied services in India, let alone the GOI, that this reasoning is plain daft. Of everyone invested in India, GOI knows first hand, the extreme challenges faced by medical education and health. A brain-drain is the least of them. If there are contrary opinions flying around, they are just reactions to the misinterpretations. GOI or its minister said nothing of the sort. GOI’s intent is simply to collect a return on its investment. That’s it. And that is an immensely fair intention. They erred in not stating that this was specifically for doctors that trained in government medical colleges.

6. And finally, why do doctors migrate?

The media focuses on money. Of course, it is the money but it is not all of it. To conclude that way and expand on it is reductionism and intellectual laziness. Fact is, doctors in private practice in India also receive a handsome remuneration. Factor in family and cultural proclivities and many would choose to stay. Most obviously do. But since we are talking about those who leave, they have reasons other than money too: 1) Professional success – the technology, quality of training and standards are undoubtedly superior. Every professional has the ambition to succeed amongst the very best 2) A more equal environment – the Indian environment is unbearably patriarchal, nepotistic and sycophantic. Hindi has a better term for it, Mai-baap. Meritocracy is not rewarded; Servitude is. Many yearn to escape this system 3) Research and publishing opportunities and, 4) Prudent commonsense – In the competitive environment of his native land, a returnee armed with a foreign degree, will always have an edge.

To say that healthcare in India is in need of urgent reform is a tired rehashing of a ridiculously obvious cliché. But, say it we must. Even if it feels like an ad-hominem attack on our collective intellect. And act on it, we will have to. When we do, will it be a comprehensive and holistic attempt at results. Or will it be yet another firefighting exercise in a public health crisis. The fate of our lives will tell.

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SHAME.

Lois Mailou Jones: Initiation, Liberia

It is all over the Internet now. I saw it on HuffPo yesterday. And on Twitter today. I refuse to copy the photograph or add a link even. If you still haven’t read or seen the vile photograph of the Swedish ‘Culture’ minister, Lena Liljeroth, cutting a cake in celebration of the 75th birthday of Sweden’s museum of modern art – Moderna Museet, you only need to Google any of them for the story. As performance art and in celebration of the “freedom of expression” and also for World Art Day, participating artists were asked to bring a cake. According to this account, the minister, (an apparent culture skeptic and critic of provocative art) was asked to cut the first cake that was rolled in after being warned that it was a performance piece. She acquiesced; the cake was rolled in; she cut it (although why specifically in the genital region, I am yet to fathom); with nary a protest (in fact, if the article is to be believed, with ‘nervous’ laughter); a photographer snapped a picture; it went viral and here we are.

To the expected outpouring of criticism, the response has been: 1) that this was ‘performance art’ and as such was intended to represent truly, the freedom of expression, 2) that the said minister is an avowed critic of provocative art and 3) that the artist is an Afro-Swede whose own head served as the muse for the cake’s screaming (literally) version (a particularly vile defence).

To address points 1 &2 (point 3 is not worthy of a rebuttal):

If you indeed have the freedom to express yourself in this way, everyone else has an equal freedom to castigate it as, sickeningly crude. This particular work deliberately picks at the already frayed seam of the African-American’s racial identity. I choose to single out the African American since the unhealed wound of the inhuman bondage of slavery is especially unique to them. It is bad enough to inflict this sort of thing on a hapless public in the name of art and the freedom to express oneself; it is even worse, to call this an artistic and intellectual effort. Nothing in the range of even ‘mildly clever’ can be used to describe this monstrous anomaly parading as art.

As for the reaction it was meant to provoke (don’t forget this is ‘provocative art’), by Mr. Palme’s condoning tone, the audience tittered nervously. They responded to this visual violence with laughter. Laughter.

Not outrage. Not angry silence. Not a refusal to participate in this not-so-smart attempt to obscure abuse as art. Any or all of these would have been a provoked reaction too. Indeed, such a response would have assuaged. Might have been an uplifting reassurance that we have kicked history in the eye and made the tough transition to our better natures. Instead, what we are left with is a macabre display that demeans art and a grotesque response that slices the scabs off our wounds and sears them anew.

Jacob Lawrence, The Libaray

Unlike other peoples that keep the flame of memory alive by the repeated regurgitation of their oppressions; the history of the African American is much obscured and in fact, denied. In the words of Ira Berlin, a celebrated historian of slavery, ‘social identity is rooted in history’. The African-American struggle with identity is mirrored by the absence of a past.

It would be useful here to remember the horror of this shameful history that used the very body of Africans as art. In her book, ‘Medical Apartheid’, Harriet Washington painfully troughs this savage ditch of our not so recent past. In a heartbreaking chapter titled, Circus Africanus, she details the use of African slaves as art exhibits and scientific specimens all over the United States and Europe, with cities like New York and Paris playing host. I list some of these long forgotten horrors from her book, in the hope that these stories of human indignity are remembered, retold, and that our collective memories will never let these atrocities rise again, in whatever form.

1. Ota Benga, 23 years, an African captured in the Congo, was exhibited in the Bronx Zoo in the 20th century (1906) in a monkey cage along with a gorilla and an orangutan.  The New York Times actively supporting this as furthering the understanding of ‘evolution’. His cage bore a placard titled: “The African Pygmy, ‘Ota Benga.’ Height 4 feet 11 inches. Weight 103 pounds. Brought from the Kasai River, Congo Free State, South Central Africa by Dr. Samuel P. Verner. Exhibited each afternoon during September.” (pp. 76-77). From the Times: There were 40,000 visitors to the park on Sunday. Nearly every man, woman and child of this crowd made for the monkey house to see the star attraction in the park, the wild man from Africa. They chased him about the grounds all day, howling, jeering, and yelling. Some of them poked him in the ribs, others tripped him up, all laughed at him. (p. 78).

Ota Benga was at long last freed. In a final act of hopeless submission, he committed suicide.

2. Black hair was described as wool (p. 78) and the features of displayed blacks were used to locate their low status on a supposed evolutionary continuum between monkeys and whites. (p. 82). PT Barnum and his traveling circus commonly used Africans in, and as, display.

3. The Khoi are a group of hunter-gatherers in the region occupied by today’s South Africa. They were renamed Hottentot by the Dutch, a pejorative term to describe their clicking language. The gluteal and labial prominence of the Khoi women generated interest amongst the differently endowed races who proceeded to equate their anatomic disposition with sexual shamelessness and immorality. One of their ilk, a woman called Saartjie (pronounced Sart-kay) was captured by the British and used as human display/medical specimen in London. Her body was subject to all manner of medical examination and procedures. Over a short period of time she went from being a medical specimen to a circus one, paraded naked in public, in parties and in street-side cages as the Hottentot Venus. She died of an unknown infectious illness at the age of 27. Even in death, Saartjie was not allowed to rest. Her body parts were displayed in jars and her skeleton hung in the Musee De l’Homme in Paris (pgs. 82-85).

The list of African-Americans that were subject to the most inhuman indignities for slavery, for medicine, or for pure exhibitionist pleasure, is simply too long to be told here. The narrative of our history has conveniently pushed their unsung tales into deep long forgotten crypts. Ms. Washington has done us all a yeoman service by rescuing them in what, I can only imagine, must have been an extremely difficult effort. Their story demands a read. Their names deserve to be remembered.

For Mr. Makode Linde and Ms. Lena Liljeroth, I have two words that they will do well to never forget: Ota Benga and Saartjie. Our time needs to give their unjust past, a grave and remorseful respect.

Review: ‘Behind the Beautiful Forevers’ by Katherine Boo

I’ve made a pit-stop at the Prologue. Its narrative style could well be the notes of a film director. Scene and frame recreated in prose; it read like a movie shot by both Shyam Benegal and Danny Boyle. But, this is not what forced the pause. The detailing of a stark and savage poverty in a lyrically descriptive style was unsetlling. ‘Yellowing cotton buds’ and ‘bellies stained in blue’.

For those of us that live with the helpless sadness of this divide, that use carefully created karmic-dharmic constructs to live with this and to continue with our own struggles; to us, it seems that only an outsider, for whom this experience has an other-worldly unrealness, could write this way. The detached, ever-observing, eye of the interloper stares with transparent lucidity through the beautiful prose. The constancy of her gaze distracts. A subject like this requires the words to translate a greater sense of the writer’s empathy, in order that it is warmly welcomed into and as our own.

KAFILA - 12 YEARS OF A COMMON JOURNEY

Guest post byMITU SENGUPTA

In a remarkable book about slumdwellers in Mumbai, Katherine Boo brings to light an India of “profound and juxtaposed inequality” – a country where more than a decade of steady economic growth has delivered shamefully little to the poorest and most vulnerable.  But though indeed a thoroughgoing and perceptive indictment of post-liberalization India, the book fits into a troubling narrative about the roots of India’s poverty and squandered economic potential.

This is a beautifully written book.  Through tight but supple prose, Boo offers an unsettling account of life in Annawadi, a slum near Mumbai’s international airport.  In Boo’s words, this “single, unexceptional slum” sits beside a “sewage lake” so polluted that pigs and dogs resting in its shallows have “bellies stained in blue.” It is hidden by a wall that sports an advertisement for elegant floor tiles (“Beautiful Forevers” – and hence the title).  There…

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What I know now about the then unknown

Pier 46

If I knew then that I could bear losing you

If I knew that living trumps grief

If I knew that after dying a thousand deaths,

I would survive with an incredible cowardly courage,

I would have spared you my terror

I might have known to laugh with you

Might have stopped fortifying our walls of sand

Put down our weapons; turned our backs to the coming gale

And in defiant surrender; I would have let us live.