Why do Indian doctors refuse to work in villages?

This post was originally an answer in Quora for the same question

This is often a derisive topic among the general public, the politicians and the doctors. I also feel that people talk and pontificate without knowing ground realities. People expect altruistic qualities from their other countrymen while they sit and criticize everyone including doctors. So for those willing to understand what the issue is here are a few reasons why doctors are refusing to work in rural areas.

Infrastructure
The government hospitals in big cities like Bangalore, Kolkata, Mumbai, Delhi, Chennai, etc themselves are not the among the best in infrastructure. Even the basic infrastructure already present is poorly maintained. Most days in a month the CT & MRI scanners are not working. This is more like a rule than the exception.  So too the instruments, microscopes, endoscopes, cautery machines and expensive diagnostic equipments suffer from the same fate. If for some reason something stops working, then it wont be fixed till the end of the year or sometimes never at all. This is the story in big cities. So expecting any kind of infrastructure in a rural set up in India is like day dreaming. 
There are hardly any drugs that are supplied to the Primary Health Centers (PHCs). At the most you would get one huge carton of Paracetamol and a 5 cartons of Diclofenac injections (painkiller) and 10 cartons of Sterile water injections (yes water!) and many more cartons of syringes to inject these. These are highly inadequate to run any kind of village health program. When antibiotics are required, even when the patient can afford (rarely) to buy there is not a medical shop for the next 20-30kms (the nearest town). How would a doctor who has put in so many years getting a medical degree feel in this situation when he can't even treat the people around him. When people do not get better how will they trust him/her? 
Some people would say why not refer? I worked in some villages 20kms from Mysore during my rural postings during internship. When we want to refer, the patient doesn't even have money to take a bus to the city. We would sometimes have to pay from our own pocket or even take them ourselves to ensure they go. If a patient with a simple throat infection has to be referred to the city for treatment it shows the dismal state of our rural healthcare. Imagine the plight of that helpless doctor in these circumstances.

Personnel
The recruitment for the PHCs is from the state public service commission (PSC). In Karnataka, one of the more prosperous states in India more than 50% of the slots remain vacant. Why do you think? The corrupt officials running the KPSC always recruit less even when enough applicants are present since keeping the demand high is very good business for them. The going rate of bribe in Karnataka for a PHC doctor's job right now is around 1.5-2 lakhs. The job has a listed salary of Rs. 30,000 - 42,000 pm! Many of the applicants are recruited on an ad-hoc basis streching from 6 months to 2 years and then the whole process starts again. Giving permanent jobs reduces the officials' black revenue.

Now we have one politician who wants to win the next election. Who can he target? Oh the new medical students graduating out of medical colleges!!! Give some speeches of doctors only making money in cities and not serving the poor, put in some fines, threaten their PG seats and the job is done. If not the media does the rest. After a year of this forced labour where the doctor is given no agenda nor help to set up anything in a village,  he's just kicked out in the open. If that student really wants to serve the villages for a few more years he has to put in all the efforts I mentioned in the previous paragraph. Will any sane man do this? I fail to understand who is benefiting from this futile exercise?

Then comes the specialists and superspecialists who are posted in the peripheral community health centers without even basic infrastructure or even a semblance of an OT. You won't get gloves, linen, sterile instruments or even clean bed in these hospitals. My oncologist friend served his 3 year govt bond after his post graduation in a remote village in Tamil Nadu. He spent everyday of those 3 years referring patients to the city, most of whom never reached there. Forget chemotherapy and radiation the medical college he served in did not even have pharmacy to buy drugs. My Orthopaedic (bone) surgeon friend served a year in a community health center doing everything from delivering babies to making house to house visits of every panchayat leader in the villages around. There were no mid-wives even. He hardly fixed a bone the whole year because there was not even material for the cast. He could not even buy it himself because his salary never came and he quit after a year. How is this stupidity helping improve rural health? Is this the best use of the specialist's expertise?

Administration
I have many of my friends working in PHCs. There is a huge hierarchy in the government medical service where too many people in the middle are hardly working. The doctor assigned responsibility of a PHC is not given autonomous control over the running of the same. 50% of his/her time is spent in CYA* in the administration rigmarole set up by their superiors to escape blame for anything wrong that happens. Rest of it is spent in seeing patients, managing lower level staff, putting up with all kinds of nonsense from the villagers, inspecting the whole village for any risks of Dengue, malaria, gastroenteritis etc. and of course getting frustrated at the system. Even the staff under him is not under his control. He cannot even fire the group D staff of the PHC he is supposed to be heading. There is so much administrative burden on this one single man and he's not even trained to do that. He just has to jump into this dirty puddle and learn to swim by himself. All he really wanted to do was help treat people in the rural areas.
*CYA- cover your ass

No scope of progress
There is no clear career trajectory for a doctor working in a rural area. They may get some reservation in the PG entrance exams but if you continue to do primary health care in the villages you don't go up the ladder at no time during your job. You will keep doing the same job at 60 what you were doing at 25. There is no mentor, forget that- not even someone bothered whether you are progressing. How would you feel to be an intern throughout your life?

Security
Forget it. I won't even speak about it. We can't seem to protect the doctors in the cities how will we even think of those poor village doctors?

Pay
I put this in last, lest people would comment how inconsiderate thinking about paying a doctor. I don't have an issue with the salaries posted but I am bothered by how they pay. 
Let me give you an example to explain. Four friends of mine are serving in PHCs in very remote villages where no doctor wants to go. They are working there because it is closer to their home. They haven't received their salaries since 6 months!!! They have a protest about this for one day and the media vultures eat them up. I know people expect doctors to be so altruistic that they should work for free but which job in the world gets done if you don't pay people for 6 months at a stretch? 
You demand why this happens and they say this minister has to release the funds and that official has to sign the papers, so it takes time. 
So how do govt employees like Bus conductors, Bus drivers, bank officials, group D and other govt officials like IAS, IPS, IFS get their salaries on the 25th of every month without this "inevitable delay" ? 
Because if you don't pay these people on time they won't turn up to work next day. Simple as that.

I'm sure there will be people disagreeing with everything that I've said above and then go on to complain about the rampant corruption among doctors, commissions they receive and sub-standard care of someone they knew. There are many people in India who are like an ostrich with it's head in the sand and thinking everything is all right. They expect solutions to fall from the sky. If they can blame it on someone else their job is done. But I would like someone to suggest how anyone would be able to improve the situation in rural areas without putting the onus on unpaid, ill-treated and frustrated doctors. 

Can someone suggest a good enough solution? 

"OMG!!! How can they ask that?"

Eulogy to Dr. APJ Abdul Kalam

The first time I saw Abdul Kalam in person was when he inaugurated the free school built by JSS Mahavidyapeeth- A Hindu religious institution which owns my Alma Mater- JSS Medical College, Mysore- in 2002.

That in itself speak volumes of the kind of unsurpassed respect he commands across all of India without any barriers of politics, religion or politics of religion.

Before this visit I had only heard and read about the "Missile man of India" from the TV and newspapers. I was was in 1st year of my medical school. We were all supposed to attend the the inauguration but all of us went there happily to hear the great man talk. He spoke to all present there- school children to college professors- in his usual child like demeanor. He asked about 10-12 school children to ask him some question. He was very impressed by some deep questions.

One child asked him.
"What is the most dangerous weapon in the world"
He thought about it for a few seconds and replied,
"Ignorance"

I remember this like yesterday even though it happened nearly 13 years ago. He absolutely nailed it with just one word. This is the kind of impact he has on our consciousness. An unapologetic dreamer, inspiring grandfatheresque figure and an optimist who breathed positivism with every word that he spoke.

Why was he so universally loved and celebrated?

He removed all the useless fluff from the presidential office. He made the president more approachable. He actually lived the life of the first citizen in it's true essence. At the same time he elevated the office of the President from the ceremonial rubber stamp it was perceived to be before he took over. He gave the office purpose and a stand.

In a country bereft of visionary leaders he truly proved to be a leader. Among all the chaff we had a gem. Whether it was his India 2020: A Vision for the New Millennium or his very famous lectures he was always a man thinking of how we can change rather than complain why we haven't. He put his point across with such an innocent charm that we were taken by him. A scientist- Statesman- Patriot that India badly needed at the time.

"A developed India by 2020, or even earlier, is not a dream. It need not be a mere vision in the minds of many Indians. It is a mission we can all take up - and succeed." -APJ Abdul Kalam

I've read his books Ignited minds and his autobiography- Wings of fire.

Very simple in the prose that it almost seems like a high school kid has written the books. But the ideas in the books were so powerful that it can shake the whole nation. He writes about his early struggles as a scientist in ADE, DRDO and finally in ISRO. How he overcame failures to finally make India a nuclear power to reckon with.

“Thinking is the capital, Enterprise is the way, Hard Work is the solution”
― A.P.J. Abdul Kalam, Ignited Minds: Unleashing the Power Within India

“Your children are not your children. They are the sons and daughters of Life's longing for itself. They come through you but not from you. You may give them your love but not your thoughts. For they have their own thoughts.”
― A.P.J. Abdul Kalam, Wings of Fire

He taught us to dream despite our limited resources and assured us that only our dreams can take us forward and make us do more than we are now. I wrote a poem after reading his book- Wings of fire about dreams.

I do not want to list out his scientific contributions which are so well known already but would like to mention that he had a significant role to play to get the India-US nuclear deal pass the parliamentary test. Like a true patriot he managed to convince a populist leader like Mulayam Singh Yadav to support the deal, which finally went through.

He supported something very close to my heart: education. A boy, distributing newspapers in Rameshwaram eventually reaching the highest office in the country was only possible due to education and he understood that all too well. His love and dedication for children was fueled in no small measure by this basic understanding of his.

"Black' Colour is Sentimentaly Bad". But "Every Black Board Makes The Students life Bright - A.P.J. Abdul Kalam

A lot of people become heroes after they die but here we had one while still alive and yet we couldn't have enough of him. I would end this eulogy for Dr. A. P. J. Abdul Kalam with this quote he made us all repeat when he gave his speech 13 years ago. I still remember it like yesterday......

“Learning gives creativity
Creativity leads to thinking
Thinking provides knowledge
Knowledge makes you great.”
― A.P.J. Abdul Kalam

Lee Kuan Yew. A great man and deservedly so.

Lee Kuan Yew, the founding father of Singapore died today of natural causes. He would have been proud of how he has left his country.

Lee Kuan Yew (LKY) will be remain a great leader even if he wasn't the most popular leader outside Singapore.

If one has to appreciate the work that was done by him one has to live in Singapore for sometime like I had the opportunity to. I lived in Singapore for about a year and completely enjoyed my time there. This one year gave me the opportunity to examine why Singapore was so successful. Coming from a country like India which got independence much earlier than Singapore it is just incredible how he converted a third world country to a first world in a single generation. This kind of feat is not matched by any leader in world history.

Of course he did not do it alone. There were other leaders too. Also LKY crushed his rivals and was not kind to dissent in his own party or even others. He ruled Singapore with an iron hand. This might seem untenable to a European or American but Singapore needed that kind of a leader in 1965. Otherwise it would have slowly degenerated into a banana republic like Zimbabwe or Myanmar. He was the leader that Singapore needed. 

When I lived in Singapore I was saddened by how India could have been as developed if not for populist and socialist Congress Party. Jawaharlal Nehru could not for all his greatness become as great a leader as LKY. Far worse he left a poor legacy in Indira Gandhi and her dynastic politics to send India into political and economic ruin. Where did India miss the bus when we got our independence in 1947? 

The difference was the vision that LKY had for his country which none of our Indian leaders had. As examples I would just mention 3 instances of his great vision. There are many more but these are instances which stand out for me.

1. Drinking water Independence
During the world war II,  Singapore was offering strong resistance to the Japanese invasion and even destroyed the bridge connecting Malaysia to Singapore. Japanese cut off their water supply from Malaysia and Singapore surrendered within three days. This may seem inconsequential but LKY took a lesson from this and built the Marina Barrage where water flowing into the sea was collected in a dam like entrapment. In 20 years time the salt water reservoir became drinking water and now Singapore is completely self sufficient in fresh water requirement. Some would have called LKY a mad man then but now you can't hear anyone laughing

2. Public Transport
Singapore got it's Mass Rail Transit (MRT) in 1987 and India got it's first Metro in 1984. Today singapore has the one of the best and cheapest forms of public transport in the world and India is struggling even in the biggest cities. To see how we in India literally missed the bus we have to realize that one had to wait till 2007 to see a Delhi metro materialize and we still haven't seen the Bangalore metro become a reality anytime soon. We were 20 years too late.

3. Human capital.
LKY realized quite early that he was not going to achieve much without any natural resources so he made Singapore the point of business for all of Asia. He created human capital. He made English one of the national languages and that gave Singapore linguistic currency to deal with the west. He did business with everyone who gave them business. China, Malaysia, North Korea, Myanmar....it did not matter. That was a very astute move for a small country to do to improve economy and avoid war from neighboring countries.

My admiration for LKY stems from the way he built a country from nothing and which now has one of the fastest growing economies and a strong currency. No Singaporean today wants to settle down in another country but several in India are dying to....and that says a lot about LKY as a leader and statesman and how far Singapore has come since 1965.

How should a medical student use his Internship?

I got asked this question on Quora

How do i make best use of internship during MBBS in India?

It got me thinking as to what internship meant to me. I finished my internship nearly 7 years back so maybe now I have better perspective on what it meant back then. I answered and I thought it would be a good idea to share it here as well.

How should you spend your internship?
Most of my seniors said study hard for your entrance exams since its so hard to crack them. I'm sure most interns would study anyway as a default. I wouldn't stress on that aspect.

I would say use your internship to prioritize your career goals.

What do you want to be?
Sometimes this question is asked too late in a medical student's life.

To prioritize your medical career you need to use your internship as career sampling. 

More than knowing what to take as a specialty you should know what not to take.

Few things I think might help you in that

1. Keep an open mind. 
Never get bogged down by other people's opinions about what you should do. What you do is your business not your uncle's or neighbor auntie's.
2. No work is too small.
Take up every role that you come across. Cleaning a colostomy tube is as important as putting in the colostomy tube through surgery.
3. Respect the patient.
Work towards making them better always and try your best not to hurt them.  Always remember that patients are your best teachers so give them as much respect as you would your teachers.
4. Take ownership of your patient. You might be just an intern who follows your unit head's orders but the patient is still yours. Try to create a personal bond between you and your patient. It always helps you and the patient. Both sides get what they want.
5. Medicine is art. 
Work hard in the wards. Your books will only take you so far but the warfield (wards) is where you learn the craft. Never belittle any ward procedures. IV lines, central lines, urinary catheterization ,repair of emergency lacerations..... You never know what you will come across in the wards. These skills you can never acquire or experience later. I did one central line during my internship and that experience was exhilarating. Being an ophthalmologist now I'll never do it again so I'm thankful I did it then. Wards and patients will give you all the inspiration you need to propel you towards a speciality.
6. Make your peace with death and disease.
Until you reach internship you never realize how much death and disease of your patients can affect you. This is because you will have a personal investment on the patient. You will sometimes feel helpless in the face of mortality and morbidity but that is necessary.
7. Find your role models.
It could be anybody you work with and even your own batchmate who has probably figured it out better than yourself. One is never short of people to look up to.
8. Recognize the wrong people. 
You will come across people who are not good at their job, people who insult and look down on their colleagues and juniors, people who are unethical and so on. Identify those people and make note to yourself never to be like them. Do not let a bad doctor ruin a good speciality option for you. I didn't have good teachers for ophthalmology in my medical school but I didn't let it spoil my opinion of ophthalmology.
9. Maintain your sense of wonder
I feel we need to find wonder in what we do and work towards what we want to be. I would advise the same during one's internship. Never lose that wonder.

Defense is the worst form of Offense

Whatever I may do,

A fault,they will surely find.

Wherever I may live,

The world is still not colour blind.

Raghuraj S. Hegde from the poem Blackie

Over the past month or so I have been really worried as to how dangerous the world had become. Two incidents have much to do with what I feel right now. 

One is a seemingly funny comedy movie "PK" released last month in India to rave reviews and incredible Box office collections. It supposedly makes fun of age old superstitions in India (Disclaimer: I havent watched the movie yet). This movie has somehow caught the fancy of self claimed protectors of Hindu culture who have denounced the movie saying it insults Hinduism and promotes 100 other blasphemous things. It would have been good if it had stopped at that but no. They had to burn posters, set vehicles and theaters on fire and also file frivolous litigation in courts. Fortunately no one has died as yet because of this movie (at the time of writing). The presence of  Hindu fundamentalists, radicalists and anarchists have been denied by the Hindu majority public for a long time. Those who don't yet believe that they exist are living in middle earth. What distresses me is not that these fundamentalists exist but that they have active support from educated and informed Indians. I found this out when the discussion about this movie was brought to Facebook, Twitter and Quora. I realized many of my old colleagues, classmates and acquaintances hold a very strong opposition towards other religions. These people have passed out of the top universities, seen the world around and yet they have such a narrow view of their own religion and other religions. Many of these people started openly posting anti-Muslim or anti-Christian status updates and jokes online forgetting so many of their acquaintances are from any of the many religions in India. Any opposition from many people were ridiculed as either "sickular" or "selfish" or "blind" or "emasculate" . These people were steadfast in their hate for other religions. They claimed that Hinduism has been insulted long enough without anyone protesting and that was because Hinduism is a tolerant religion. From the vile I saw in online media Hinduism was anything but tolerant. I know it is not true. I am a Hindu by birth and proud of it. I do not see it as a religion but as a way of life. Hinduism is one of the few religions in the world which gives you the freedom to be an atheist but still belong to the religion. I presume most of these Hindu fanatics do not realize how open minded Hinduism has been and will be. You don't need 10,000 people burning posters and effigies to protect a 5000 year culture. It can stand tall on its own.

The second incident was the assassinations of cartoonists and editors of 'Charlie Hebdo' by a few of misguided French Muslims. This has again started a debate as to how this came to happen. Commentators wrongfully point out that the Charlie Hebdo bought it on themselves by publishing blasphemous cartoons over the last few years and that this would have happened sooner or later. They also go on to say that all this would not have happened if the magazine was more respectful of Islam.

Really? I mean are we even considering this argument?

As a citizen of the world and living in a democratic country I would want to have my own opinion and not things thrust upon me as politically correct. If not anything I should have the right to be offensive. Weather I choose to use that right is another matter entirely. As long as my words,writings and forms of expression do not harm anyone I have the right to say it.The 2006 article by Christopher Hitchens explains it so brilliantly here. If our only aim in life is not to offend anyone then we would see something like this in the future.

Anything you say is offensive to someone else so what should you do? Should we just stop talking or expressing? One is just waiting for the other to be "offensive enough" to start any of the following- protests,tearing posters, rioting, frivolous court cases, mass murders and genocide. If our attitude remains to encourage the above and stifle all forms of expression then soon enough we would be no different from people in China, North Korea or Saudi Arabia. 

How can you be even sure any harmless thing you say is not offensive to someone else. You can never be careful enough. If you as an individual find something unacceptable or offensive choose not to promote it, watch it or even publish it. Tearing up posters, burning movie theaters, killing cartoonists and policemen isn't going to change anything. Every religion deserves the right to be criticized or praised in the same measure. I don't believe that religion should not be debated or discussed. How else would we improve our religion to suit our modern world. If we had not debated or discussed religion we would still be practicing all the weird old practices of our forefathers. As a Hindu I have the right to question my religion and so does a Muslim or a Christian. We have to see the merits and demerits of religion as one sees himself and not how a particular religious organization decrees we see it as. If we are scared to question we will not progress. All I want to say to these people is. Thank you. I can think for myself. Please respect my intelligence.

Raghuraj Hegde