Doctors claim that they are engaged in genuine health care. The quality and quantity of the air we breathe, the water we drink and the food we regularly eat are prime determinants of our health. The lifestyles that we follow in our day-to-day living will add to these in deciding whether we would stay healthy or would develop diseases. But by giving medicines, removing and repairing organs or even transplanting them after a person has become a patient, are doctors really engaged in health care? Diseases are the result of neglected health care. All diseases known to mankind are directly or indirectly due to problems in life style, diet and environment. The issues involved might be very obvious in some cases, but are not so in some other cases where it might have occurred in the recent past or remote past. The issues or causes would have occurred in the previous generation in case of genetically transmitted diseases. In the case of infectious diseases, the causes are often clear; it might appear as if it occurs due to some pitfall in hygiene and sanitation (both personal and environmental) where the organism gains entry into the host. Even in these situations the role of nutrition is conveniently forgotten; the organism establishes strong foothold only in the body of a person with weakened immune status – the cause of which is malnutrition.
We are oblivious of the fact that malnutrition is the most important health care issue for us. Even in the case of lifestyle disorders like diabetes, heart attacks, stroke and cancers, there is a strong factor of malnutrition in the form of overeating or deficiency of protective elements in diet, and exposure to various toxins through sources like alcohol, pesticides, chemicals, preservatives and food additives such as artificial colours and flavours. To put it in simpler terms – no disease on earth is due to a single etiological factor. Doctors with narrow vision and interest often fail to identify multiple factors, which are easily modifiable, and involved in the etiology of diseases. Even cancers and genetic diseases are due to a multitude of such problems and the problems can always be traced to diet, lifestyle and environment. The mutations in gene, which cause inherited disorders and cancers, are also the result of one or more of these environmental, dietary or lifestyle problems, which escape our attention. The genetic mutation in cancers is usually confined to the same individual if he/she dies due to the disease and fails to transmit it to the next generation. But in case he is a cancer survivor, he might transfer the already modified gene (susceptibility gene) to the next generation. In the case of inherited disorders like haemophilia, we know that fresh mutations occur, the causes for which are obviously the same. At some point in foetal development, the mutation occurs due to wrong diet and lifestyle habits or some unseen environmental issues which the prospective mother carrying the foetus is exposed to. Since the individual born with the mutation is capable of living to adulthood and procreate, she/he invariably transmits it to the next generation. To give one example, the reason for diseases like Haemoglobinopathies (for example Sickle cell disease, Thalassemia, G6PD deficiency) in the developing world is only because of the presence of malaria in the community. The body modifies the red blood cells to escape from the attack of the parasite. It is the long term consequence of the existence of malaria in society. Why malaria exists is basically because of poor waste management and malnutrition. Can we ever solve health problems by studying the blood or gene of the individuals with disease? Can we cure all these diseases in every individual with medicines, surgery, organ transplants and the therapy of the future – gene therapy? On the other hand, we can certainly improve nutrition, lifestyle and waste management and wait for a good outcome for the next generation in the form of reduced disease burden and improved quality and quantity of life for each individual. To identify the etiological factors in diseases we have to study the individual as a whole- his lifestyle, his dietary habits and his environment in its totality. This is what, as doctors, we should be teaching people – because doctors are teachers.
After making available basic health needs to all citizens, we should then focus on basic disease care facilities. Ultramodern and high-tech treatment facilities should not be included and conceptualised as part of basic health needs. As such, treatments are damage repair facilities, it makes no sense in producing more damage and providing more damage repair facilities, no matter how big or modern they are. Hi-tech or super speciality hospitals should be the last choice for any form of society. To provide basic disease care, we need more family doctors or general practitioners. But over the last few decades they are becoming rarer and rarer. Because of wrong polices or a lack of policies, family physicians have become a vanishing species in India. We need to revive the system, for which the MBBS curriculum has to be modified suitably. If we are human beings interested in the health of our fellow beings and welfare of our country, we need to bring about a radical change in the health care scenario. India is probably the only country wasting resources by ignoring health care and concentrating only on setting up super speciality hospitals for treatment. Many developed countries in the world like UK, Canada, Denmark and most of Europe and Australia have a strong referral system where the GPs/family doctors are the key players in disease care. In all these countries, specialists are not given undue importance and patients have no direct access to them. Even the remuneration and respect which General Practitioners (or family doctors) get in society are better compared to specialist doctors. They also have a perfect basic health infrastructure and consequently have a very low disease- burden as compared to India and other developing countries or under-developed countries. The disease care scenario has deteriorated to organ based super speciality approach alone in some developed countries like USA and their followers like India. But the majority of these countries (except India and some African countries) have perfect basic health care and the disease burden is very low for them. Even USA has realised the mistake of ignoring primary disease care (family doctors) and are in the process of taking corrective steps.
Therefore it is a social need to change the curriculum of MBBS training, to encourage family doctors, as a national objective. This is because specialisation in any field, especially in disease care, will evolve as a natural process, because of several humane weaknesses, including the need for ego-satisfaction, greed for money, easy fame, and even some amount of laziness. But the cost effective and challenging job of basic doctors/ family doctors who have to act as friend, philosopher and guide to families or individuals, needs tremendous amount of patience, interest in human beings and all their problems, along with very good communication skills. They will be there only if the nation has a plan and will naturally disappear if we are weak with our planning. Before the curriculum change, we need to prepare the grounds for it by educating the public and authorities about what is happening in health care and disease care in India. We need to work for a health policy and implement necessary economic and social reforms to produce more GPs or family doctors. If we want to bring back GPs/family doctors we should introduce a referral system by introducing strong legislation, ignoring protests from the uninformed public, medicare industry and its supporters. The MBBS curriculum needs to be modified to produce primary care doctors who will be given training to work as GPs as is being done in Denmark, UK, Canada and several other countries. General Practitioners should be the first contact doctors who will look after all individuals under their care, irrespective of age and gender. A fixed number of families or individuals can be registered with each GP and they should consult only that doctor for all their problems. People should not consult a specialist unless and until the GP refers them to a specialist.
In India, doctors are becoming specialists because they gain respect and encouragement from people and the government only when they become one.GPs are neglected by the government, and the people are given the freedom to go to any specialist of their choice: this practice is unheard of in any good health care system. This leads to doctor- shopping, increased cost of medicare and other unhealthy trends in the system. Referral system is not referral protocol as some doctors think. In Kerala, the health secretary once made a genuine attempt by entrusting some doctors to formulate guidelines for introducing a referral system. But by making protocols for referring various diseases they scuttled it. Referral system needs legislation and policy change and not just guidelines. The common man and economy will suffer heavily in the years to come if we don’t introduce a three tier referral system by legislation. We will have to identify doctors who are willing to practice as GPs and then permanently register a certain number of families with each one of them.
The permanent solution to our problems lies in providing genuine health care by making available all the basic health needs to all sections of society. These include providing balanced diet and safe drinking water for all, proper and prompt waste management, good sanitation facilities, and encouraging and educating people to follow good lifestyle practices while providing facilities for that like playgrounds and parks. Providing basic health needs will reduce the disease burden in the community. This is possible only if we aim at human development and providing social security to all individuals in the society. Therefore the situation calls for strong economic and social reforms. After that we need to streamline disease care by focusing more on basic disease care. Health care should be unambiguously understood as prevention of diseases and promotion of health alone. Disease care is not genuinely a health care activity in its true sense, but can be transformed into health care if doctors recognise what went wrong in each patient and teach the patient and the attending relatives, in the hospital setting itself, about the prevention of that disease. If we want to have people-oriented health care, then what is needed is a stable pyramid of health care. But we have ended up producing an inverted pyramid, which is collapsing, and has resulted in increased number of diseases. The sad part of the story is that neither the general public nor the doctors and the administration recognize this danger. The earlier we recognise this, the better it is for us and the rest of the world.
The author can be contacted on Twitter at @PKSdharan