THE QUALITY OF MEDICARE
Major M.P. Vora
The Bombay Civic Journal
Vol. XXI, No.4 of June 1974; Pages: 23-27
It is a sad confession; indeed, to make but the truth must be told however unpleasant it may be. The standard and quality of medical services to venereal patients has remained disgracefully pout of date and discredited. In this observation, there is not the slightest exaggeration or distortion. The quality and content of medical services to venereal patients has been of late a frequent target of attack. It takes a kind of perspicacity and discernment to bring to the public notice the glaring defects I the health care for venereal patients. This critical view may come as a great shock to the public. But it should be welcomed and examined carefully for it has sane and constructive intention. The scathing criticism as appeared, from time to time in the press and has come from local as well as foreign experts who happened to survey conditions in the country. The standard of healthcare received by these patients either from general practitioners in medicine or public or private hospitals has not been up to the mark and far from satisfactory. Nay, the writer would call it not only useless and incompetent but also most dangerous. Its grave and devastating impact on the health of the sick, his family, and community in general and national economy has been totally ignored. All ways of judging quality and standard of medical care for V.D. patients show a distinctly dismal picture. Improvement or excellence is ought through criticism and above all self-criticism one has to become accustomed to scrutiny of one’s work by colleagues, self-audit and audit by others. It is most needed and least welcomed. But it must become a habit, if one is to improve one’s standards and efficiency.
A great paradox in medical progress is the steady and sustained rise in the incidence of venereal diseases despite the recent advances in the methods of diagnosis, treatment and epidemiology. The over-all picture of the V.D. control programme in the country is very disappointing, ill-planned and unorganized. The most important and striking social development of the last decade has been the change in the sexual attitudes and behaviour of the large section of the population, greater freedom and independence of young girls and women. There has been an abrupt and sudden swing in public attitudes in favour of sexual activity in all its forms. Along with this, is the greatest upsurge of venereal infection ever known during peace time? However medical services and personnel associated with venereal work have not kept in pace with or have not been fully aware of these sweeping alterations in public attitudes. Today, an increasing number of people regard venereal infection as an accident of sexual activity to be dealt with rapidly, efficiently and then forgotten. On the other hand, most of the patients in our country are quite content to be relieved of their symptoms only. Their gross ignorance about these infections is evident.
These can be cited ad infinitum and ad nauseum to provide proper medical services to venereal patients. Nearly cent per cent failure or non-performance is common.
Most of the clinics established in the country are only on paper. Their organisation, set-up, staff, equipment, work and procedures leave very much to be desired. Unsympathetic and inhuman attitude, inadequate or inconvenient timings, inordinate delays, lack of privacy, want of respect for the individual, inefficient or insufficient treatment, failure to trace contacts, failure to carry out laboratory tests for the confirmation of diagnosis or cure, absence of trained personnel, want of modernizations, meager finances etc. are conspicuous by their presence. These clinics rarely furnish reliable statistics and persons in charge show no dedication, responsibility. Here qualifications are not of primary concern. Hence, it is now increasingly realised that management of V.D. can no longer be left to amateurs but must be entrusted to professionals.
URGENCY OF MEDICARE
Venereal disease in one form or other is very common in the practice of most practitioners in medicine. It is a most potent and frequent cause of illness and may involve men, women, and children of different ages. Its manifestations may be obvious, trivial, hidden or so diverse as to cover the entire range of medicine. It is not uncommon for these patients to get themselves admitted in medical, surgical, E.N.T., ophthalmic, gynaec, cardiac, or neurologic wards for various complaints, the origin of which is uncured venereal infection. However, the co-operation of specialists in other branches of medicine is hard to come. The general practitioner in medicine is the back-bone of health services and is first approached for medical advice and help. His main role is and must always be that of a primary diagnostician and therapist in medicine. It is vital to preserve him. However, his education and training in venereology and venereal work is very inadequate and marginal. It would not be far from truth, if the writer was to say that he ahs had no educational and practical training in the subject. He has usually no laboratory facilities at his disposal either for confirmation of diagnosis or ‘cure’. During his study, he has not developed a co-operative attitude towards the control of V.D. He has hardly any time or inclination to trace the contacts of the patients, he treats, Most of the patients receive what is called “Therapeutic approach”, “Hit-or-miss” or “shot in the darkness” therapy, without any recourse to the basic principles in the management of V.D. This trend, which is in vogue all over the country, offends every normal requirement and has dangerous potentialities. In fact, the way venereal patients are dealt with is nothing short of quackery and amounts to mockery. Humane attitude, proper physical examination, correct diagnosis, its confirmation by laboratory tests, education of the patient with regards to his or her infection, investigation of the contacts, proper and adequate treatment, follow-up tests of cure, record keeping etc., the very basic procedures in the management of V.D. are rarely done even in the so-called teaching medical institutions. This is very shocking but absolutely true. These mouldy features of medical services ought to have been discarded long ago but they still persist with remarkable tenacity. It is simply criminal to relieve merely symptoms alone in contravention of the percepts of normal therapeutic rationality, when there is an effective way to deal with the cause of the disease. These flagrant examples of medical negligence and scandalous frauds perpetrated on the ignorant must cease immediately. The dangers of unskilled services are obvious in the steep rise in the incidence and prevalence of V.D., incalculable human sufferings, needless deaths and disabilities and financial loss. Even to this day, no remedial measures are contemplated to correct the critical situation. It is no wonder that the elite public has little confidence in the quality and content of medicare for venereal patients. Especially when the incidence of V.D. is very high the most important task of any physician is to recognise these diseases in the every early stages, treat them properly and adequately and to contain their spread. But is he or she in a position to fulfill these stipulations and discharge responsibilities? No. How can this inability be condoned or excused? Doesn’t this invite law suits for medical negligence or incompetency?
EDUCATION IN VENEREOLOGY
There is curious ambivalence, in the country, regarding the place of venereology in medical education. It is not realised that the quality of medical services depends on the proper education and training in venereology for medical students. Unfortunately, the curricula of most medical colleges in the country totally neglect the study of V.D. though of utmost importance. This has naturally resulted in the deterioration in the teaching and training of medical students, and poor attendance to venereal patients. A few remarks of different authorities on the subject will not be out of place.
Dr. B.A. Daruvala, a noted teacher of the University of Bombay had to opine that, “Even those awarded the double post-graduate qualification in dermatology and venereology are unadulterated dermatologists with no knowledge and little interest in venereology.”
Dr. R.V. Rajan, well known authority from Madras said: “In most of the teaching hospitals, the standard of organisation and performance of teaching and training and medical care of V.D. is nothing to be proud of.”
Dr. C.S. Nicol (1971) the British expert, during his visit to different centres in India could not fail to notice a vast difference in the quality of medical services rendered to venereal patients by separate departments of venereology as against those by departments of ‘derma-to-venereology’ (very common practice in the country). He was frank enough to express his dissatisfaction of the Indian system of specialising in dermatology and venereology jointly. He said, “If India is to contain its present critical situation and prevent further increase in V.D., which will occur in the next decade, she must maintain venereology as a separate subject in the field of medicine both in the undergraduate and post-graduate teaching at the universities and must establish institutes of venereology and laboratories in every state.”
Dr. M. Candaw, the last W.H.O. Director General (1973) said, “Professional and public laxity and ignorance are the main reasons why venereal diseases are reaching epidemic proportions. The main reason for lack of action is inadequate health education of the public complied with the fact that medical and other health personnel often lack familiarity with venereal diseases or underestimate their importance. Sex education is deplorably inadequate. Quick action is essential before these diseases become completely out of control.”
Even the deans of Medical faculties of Universities in India at their conference held at Bombay in 1970, were constrained to deplore the sorry state of affairs with regard to teaching and training in venereology and demanded the recognition of venereology as a distinct and separate speciality.
The Times of India, Bombay, (November 7, 1971) while writing editorially on the “The V.D. Scourge’ said, “Medical educationists will do well to shed their old ideas.” Strongly deprecating the tendency to link venereology with dermatology, the article said, “It is high time that the study of V.D. is entrusted to a separate department and a separate chair of venereology is established in Universities.”
The Bombay Social Hygiene Council, “a solid body of experts in all fields of venereology to inform, orientate and advise”, (which celebrated its Golden Jubilee in 1968), had demanded unanimously by its resolution of 1958, recognition of venereology and dermatology as two separate specialities and condemned the tendency to group these together either in hospitals or medical colleges.
A similar demand was made by the V.D. Advisory Committee, Maharashtra State in 1967.
FAILURE TO ACT
However, all these remarks have failed to evoke a response of the bureaucrats in the country. Delays in action have now become endemic and perhaps irremediable. Ironically, every trick is used to stifle and discourage new ideas or innovations and thwart initiative. A university chair in venereology is essential and one ardently hopes that it will not be long delayed. This will offer true guidance and inspiration and the subject will receive better attention than at present. Emphasis will be on the scientific diagnosis proper treatment and control of V.D. Besides, it will help to make workers take their art and craft seriously and initiate research. However neither Indian universities nor the Medical Council Of India, whose elementary duty is to maintain proper standards of medical education and services, are least inclined to consider these progressive measures and effect appropriate changes in their policy with regard to venereology. Not only that, the Medical Council had the stupidity to give a fresh lease only recently to its out-dated and ill-conceived policy of “dermato-venereology”. What is worse, even the official agencies managing E.S.I.S., C.H.S., public and private hospitals are found to suffer from irrational ideas of Victorian prudery and are unwilling to appoint qualified venereologists staff and provide proper medical services to venereal patients in their establishments, though this can be done easily and without much extra financial burden. This continual apathy is inexplicable. No wonder, “more than 90% of the venereal patients have to go without proper medical care even in the city of Bombay”, which can boast of many fine hospitals. It would be difficult to imagine needless deaths and disabilities that occur due to incompetent medicare. The survey of industrial workers in Bombay had shown 125 sero-positivity rate, which speaks for syphilis alone. There are many venereal diseases, which are more frequent and common than syphilis. The leading cause of disability among workers is syphilis according to U.S. Public Health Service study. However, the Committee on the prospective planning of the Employees’ State Insurance Scheme could not spare a word on venereal disease services to its employees during it s deliberations. It is matter of great regret that nothing is done to meet employees’ basic requirements of health care (venereal), though they contribute towards the cost of medical services. Isn’t it the fundamental concern of the welfare state to ensure the good health of her citizens?
Adequate and proper education and training in venereology for medical students, generalists and intending specialists ought to be provided in all teaching medical institutions. In fact, this must go high in the priority list. However, most of the medical colleges and Universities remain totally unconcerned. There is no doubt that things could not have come to the present sorry state but for the insistent, inaptitude of medical educationists, health authorities and the Medical Council of India. One hopes that the speciality of venereology will be established firmly and perpetuated by regular appointments of venereologists at all general hospitals and knowledge of sexually transmitted diseases - bacteriological, serological, viral, social and epidemiological - will find rightful place in the teaching and training of medical students. It makes no sense to deny venereology its due and rightful place in medical education, training and in planning health care.
The quality of medical service to venereal patients has remained out-dated, inefficient and insufficient to the determinant of national health, happiness and economy. Attempts must be made to improve it in consistence and consonance with modern norms. All that we have done so far is to shut our eyes, ignore the serious problem and learn to live with it in a passive, non-dynamic and fatalistic way. Such callousness, apathy and total disregard for the public health and welfare would be rare to find any where. It is sad to say that ignorance and prejudices concerning V.D. are to be found even within the medical profession as in the laity. Though V.D. is the world’s third most prevalent infection, its importance is underestimated or neglected. Indeed, it is a sad commentary on our inability to move with the times and keep pace with scientific and technical developments in the control of V.D. It is essential to call for a determined crusade against V.D., if the nation is to survive the challenge of time. Difficulties whatever they may be, are not insurmountable.