Letter from Chennai

A rational proposal to revamp and revitalize Chennai corporation’s health service

I was puzzled to read an item in the newspapers that 60 posts of medical officers in the Chennai Corporation were unfilled despite advertisements and walk-in interviews. The salaries are more or less on a par with those of the Tamil Nadu Medical Service (TNMS), and private practice is permitted outside their official duty hours. In the TNMS, the post of medical officer in the primary health centres (PHCs) near Chennai is in great demand. The doctor is supposed to live near the PHCs, but in fact many live in the city and practise here, and attend the PHCs only during daytime working hours. Why would a doctor turn down employment in the corporation when he could earn the same salary, live legitimately in the city and practise here? I turned to the man who knows more about the Corporation Health Service than anyone else, the former corporation health officer, now retired, Dr P. Kugananthan. Very kindly, he spent some time with me and answered my questions, and also permitted me to quote him in this column.

Dr Kugananthan was one health officer who was genuinely interested in promoting the health of the city. He introduced a preventive health programme, and brought 150 of his colleagues to hear me speak about the prevention programme of the Kidney Health Trust. He and I were equally disappointed when I threw the floor open to questions after my talk. I was asked numerous questions, but they all pertained to the treatment of the renal problems they faced in their practice. Not one person asked for more details of the prevention programme. The majority of doctors prefer treatment to prevention, but I hoped medical officers of the corporation, whose prime duty is to keep us free from disease, would be more enthusiastic about nipping disease in the bud.

Dr Kugananthan felt part of the reason for doctors not opting for corporation service is the lack of opportunities for promotion, as only a few senior posts are available. Another reason is interference from councillors. Doctors are not supposed to work under them, but all politicians consider themselves as the bosses. Another problem is inadequate provision of paramedical support staff. He feels the ideal solution would be to make this a branch of the state medical service and rotate government medical officers through these posts. The Corporation Health Service could be amalgamated with the State Health Service and avenues for promotion could be opened to all the staff. Another option would be to co-opt family physicians on a part-time or full-time basis to supervise clinics from 7 to 10 a.m. and from 5 to 10 p.m. The large population of people on daily wages could conveniently avail of healthcare free of cost as envisaged by the National Urban Health Mission (NUHM). Doctors already in general practice could each be allotted a population of 5000 to 10 000 for primary and preventive healthcare and paid through a voucher system by the NUHM. Dr Kugananthan feels this would pave the way for a public-private partnership involving practitioners, with private and corporate hospitals that would provide primary, secondary and tertiary care at an affordable cost to government, and a reduced burden on the public who sometimes spend half their daily wages on healthcare.

We spoke of a few other problems. It would make sense for garbage disposal and drainage to come under the health department of the corporation, and have the engineers dealing with these aspects work in collaboration with the health officer. Unfortunately, the engineering department is completely occupied in major development works such as construction of flyovers and storm water drains. That explains the sorry state ofhygiene on our roads. In fact, he says, large sums allotted to the NUHM are not utilized, and could serve urban health better by being used to strengthen the corporation's health activities. These sums could usefully supplement the corporation's health budget of ₹50 crore to upgrade the quality of healthcare for the city.

There is a clear case for paying more attention to non- communicable diseases. Of the average 75 000 deaths in the city, 30 000 are from coronary disease, 11 000 from strokes, and 10 000 from renal failure and lung diseases, and most of these could be prevented by early detection and effective domiciliary treatment of diabetes, hypertension and respiratory diseases. About 28 lakhs of Chennai's citizens live in slums. A large population of migrant labour from the northeast are involved in large construction projects in the city, and in the hotel industry. They live in slums near their place of work, and have no access to healthcare. It is a mistake to relocate slum-dwellers to places far outside the city, thereby depriving them of all sources of income, and then leave them to fend for themselves. On a visit to Shanghai a couple of years ago, I was struck by the absence of slums though there were many workers involved in manual jobs. I found that all slum-dwellers had been relocated to large multi-storey housing projects outside the city, where they had access to good schooling and healthcare. They were transported to the city for work in buses especially for their use. Perhaps we could plan something on similar lines in Chennai. So much could be done to improve their housing conditions and thereby their health indices.

We should encourage and empower outstanding health officers to do their work without political interference. Putting them into the mainstream of the state health services would give them greater incentives and opportunities to raise the quality of preventive and primary healthcare and improve the lot of the urban poor.

The Milk of Human Kindness Has Curdled

Some months ago I wrote about a pair of medical students from Chennai who dropped a dog from the roof of a building and videographed their inhuman behaviour. We were shocked again when four students of the Christian Medical College (CMC) at Vellore outdid them. While the CMC Hospital is in the heart of Vellore town, the college and the student hostels are some distance away, in the midst of an idyllic wooded campus. Simian incursions are common. Perhaps one monkey encroached into their room and they wished to teach a lesson to the entire breed. An animal rights activist, associated with the People for the Ethical Treatment of Animals (PETA), got to know of this and made a complaint to the college authorities. The animal had been killed and buried behind the hostel. The body was exhumed. The limbs had been tied with a wire, the neck and lower limbs were found fractured, there were stab wounds on the neck and she had been impaled through the anus.

The animal belonged to a protected species, and presumably the law will take its course. The would-be dog killers of Chennai were fined and allowed to continue their studies. I believe they, and their Vellore compeers, should be summarily expelled from their colleges. They have shown savagery making them unfit for the profession of medicine, for which compassion should be an essential requirement.

Meanwhile, every maj or political party in Tamil Nadu registered a demand for jallikattu (the ‘sport’ of bull baiting) to be reintroduced, notwithstanding the Supreme Court directive banning it. They wanted the Central government to pass an ordinance to bypass the Supreme Court in this matter. The Central government did not oblige. One Union minister who hails from Tamil Nadu, Mr Pon Radhakrishnan, tendered a public apology to the people of the state for having failed to bring back the sport. The politicians also demanded that PETA should be banned. They said that banning jallikattu would lead to loss of our indigenous breeds of bulls. They swore that the animals were actually being worshipped and loved during jallikattu. This is blatantly false. The Indian bovine is generally docile, and there is no attraction for the masses in walking around with them. It is well known that they are intoxicated with alcohol and irritated by chilli powder in their eyes and nostrils, and that makes them aggressive. They pose a threat to themselves and to people around.

Meanwhile, jallikattu was celebrated in a few villages despite the presence of a posse of police. Our neighbours in Andhra Pradesh also conducted a jallikattu. Two bulls, intoxicated with alcohol, ran across a railway track and died under the wheels of a train. The papers reported twelve injured persons, fortunately none fatally. However, another forbidden sport, bull racing, took a life in Tamil Nadu when a bull took fright and charged a group of spectators, goring one to death.

One can expect politicians to jump onto any bandwagon that might fetch them some votes, but I was astonished when the student community launched a massive rally demanding that PETA be banned, and that jallikattu be reintroduced, defying the Central government and the Supreme Court. I always thought students would be more likely to demonstrate in favour of ethical and idealistic causes, and was convinced that they had been put up to this by some political party, each of which has a student wing. I was wrong. Some politicians who tried to join the students were chased away by them. They said they did not want to be used by politicians who betrayed the people. They complained that all state funds were being diverted to freebies and nothing was spent on genuine development, that their employment opportunities were severely limited, that civic infrastructure was rotting away. In short, they voiced most of the grouses I have been ventilating in these columns. We are on the same wavelength in everything except their desire to torture cattle and endanger humans, an attitude I cannot understand from the bulk of the student community. When I was associated with the medical colleges of Tamil Nadu as a student and later as a teacher, the vast majority of students would have been strong supporters of PETA. Has our cinema culture sapped our humanity? Violent ragging persists in our colleges despite legislation banning it and occasional strong action by authorities. When man's inhumanity to man rules our deeds, what chance do animals have?

The government yielded to this pressure as the students continued their massive protest on the Marina beach. The Central government, realizing that all present and potential political allies from this state wanted to withdraw the ban, said that this was a state subject, and they would not object to Tamil Nadu passing an ordinance declaring that bulls were not performing animals and were exempt from any laws pertaining to cruelty to animals. The Supreme Court kept silent, and the ordinance was passed. Jallikattu was held at a few places on 22 January 2017. The result: two people gored to death, 174 injured. A day later, a policeman, on duty to make sure jallikattu was played by the rules, was killed by a bull and, one day later still, one more bystander. And our students and politicians are agitating for this? Madness! Madness!

Simple Arithmetic

The Hindu carries a report, datelined 14 January 2017, that hospitals and nursing homes in Dakshina Kannada, a region of Karnataka, will stop all procedures under various health insurance schemes of the government as there were outstanding dues of more than ₹200 crore, and no payment had been made in the last 9 months. Further, government reimbursements covered only 70% of the cost of consumables, and did not take into account salaries and establishment expenses. Many hospitals in Telangana and Andhra Pradesh had already opted out of these schemes. As I pointed out in an earlier letter dealing with the Union budget for the current year, the country does not have enough money to provide services such as dialysis and transplantation to all Indians with end-stage renal disease. It is time our leaders, both in the states and the Centre, stopped deceiving us, and took up a sensible prevention programme.

Heroes Among Us

Janab Haji S. Madhar Sha died on 6 November 2009. I had never heard of him before that. No one in Chennai could have failed to recognize his name after his death. There were notices in the obituary column that spread to several pages over several days, three full pages on day one. I have never seen that number of notices for any other person. A Muslim patient, a resident of Chennai, came to see me. After I had dealt with his illness and given him my advice, I asked him who Madhar Sha was. I was astonished at his response. He sprang to his feet. He said there was no greater person than Mr Madhar Sha. Apparently, he started as a small textile dealer, but the striking thing about him was that he would help anyone who needed his support, in any way he could. His help was not restricted to his co-religionists. Any supplicant could approach him, and none would be disappointed. Since he was in the textile business, he could more easily help people in that field.

The Hindu of 6 November 2016, seven years after his death, had 23 references to him, each with a photograph. From the names of the firms, all textile businesses, that acknowledged his help with gratitude in these notices, I deduced that three were clearly Muslim, one was Christian, 15 were Hindu, and four had secular names. Fifteen Hindu against three Muslim for a Muslim benefactor! I still do not know much about him or his life, but I salute him. There are so many great industrialists who are remembered in the obituary columns years after their death, but I have never seen more than two or three notices, and these usually from their own firms or families.