Letter from Mumbai

The Need for an Indian Medical Service and Subordinate State Medical Services

The seventh schedule of the Constitution of India (Article 246) includes ‘Public health and sanitation; hospitals and dispensaries’ as a state subject (List II–State List I). However, the Government of India continues to hold many of the strings in designing health policies and programmes, founding and funding centres of importance such as the National Centre for Disease Control and Indian Council of Medical Research and agencies such as the Department of Biotechnology and Department of Science and Technology with huge financial resources.

Central and state governments have never considered matters concerning health and the care of the sick a priority. Evidence of this is easily gathered from the outlays in their annual budgets since 1947 for healthcare and medical education as a proportion of their total expenditure. The consequences are obvious to anyone who has ventured into the poorer areas of cities, small towns and villages and attempted to study primary health centres. Is it any wonder that the healthcare of the poor is abysmal? They must often travel hundreds of kilometres when ill to seek good medical care. This is at immense personal cost, morbidity and, in some cases, death en route.

When the East India Company and, later, the British Government in Calcutta (now Kolkata) attempted to develop a system of medical education and care in this country, they did so through a covenanted agency—the Indian Medical Service (IMS)—similar to the Indian Civil Service (ICS). In 1858, when the administration of the country was taken over by the Crown in Britain, medical officers in the presidencies were granted the Queen’s Commission. The IMS regulated the creation and staffing of medical colleges, hospitals in cities and towns and a system of primary, secondary and tertiary care. The calibre of officers in the IMS can be judged from the fact that they also contributed to the development of other sciences in India— such as criminology and fingerprinting, geology, botany, zoology, chemistry and the telegraph.

Faults such as inability to recognize and develop competency and excellence in Indian physicians cannot be brushed under the carpet but the fact remains that the IMS set up a superb system of healthcare throughout India, not neglecting villages and small towns. This service also enabled modifications of systems and care in the states from 1919. From 1947 onwards, while the ICS continued to function as the Indian Administrative Service and thus provided trained officers throughout the country functioning under a system similar to that before independence, the IMS was disbanded with no efficient, nationally relevant replacement.

The damaging effects have come into sharp focus during the current Covid pandemic. The series of events that followed the plague epidemic of 1994 are being replayed, no lessons having being learnt. You will recall that the Government of India then appointed a committee under Professor V. Ramalingaswami to investigate. Six months after pneumonic plague struck Surat, despite the deliberations of this committee, the Director-General of the WHO stated that the geographical origin of the disease remained unknown. The statement in The New York Times (14 March 1995, Section C, page 10) was damning: '…Poor research laboratories and an initial panic among medical workers probably resulted in the destruction of valuable bacteria and other samples that could have helped later investigators.'

The reputed laboratories of the past such as the Central Research Institute, Kasauli; Pasteur Institute, Coonoor and Haffkine Institute, Mumbai had almost disintegrated due to political interference and general neglect. We lack a centralized agency that could carry out a systematic, well-planned series of investigations throughout the country without any hindrance. We also have no means for the execution of preventive and therapeutic measures uniformly in all states and Union Territories. Politicians dominate newspaper and television headlines. We witness territorial disputes, accusations and counter-accusations. There is difficulty in identifying the truly responsible and authoritative players in the field.

A body such as the IMS could have coordinated the services of experts in virology and epidemiology, preventive medicine, clinical pharmacology and therapeutics; streamlined studies; ensured the uniform application of scientific, practical, preventive and therapeutic measures, helped promote rational public thinking and the avoidance of panic.

Epidemics apart, an IMS will ensure uniformity in healthcare, medical education and research with purpose, sense and direction. The sine qua non for the IMS to function thus—as is the case with any institution of importance anywhere in the country— is its composition. Its constituents at all levels, must possess proven expertise, dedication, honesty and sincerity and be divorced from politics, nepotism and corruption. Indeed, these must be the only criteria for their selection to the service.

Obtaining Books Free of Cost

Many medical students are from families that struggle to make ends meet. Those fortunate to gain admission to colleges run by the government or municipal corporations are spared the horrendous expenses that must be met in ‘capitation fee’ colleges. Even so, the former must, perforce, study from books that have grown progressively expensive. Buying a set of books to cover subjects taught during each term can pose formidable challenges. It is true that books by Indian authors, published in our major cities are less expensive than those by international experts from multinational publishers.

Studying in the library, using books purchased by the college, was the earlier solution. Students using this facility faced two problems. There were several claimants for each book and librarians found it necessary to loan books for limited periods to each reader. This difficulty was exacerbated as examinations approached. The other difficulty was predominantly faced by those who did not stay in hostels attached to the college and had, perforce, to leave at a reasonable hour to make their ways home. Not for them the ability to stay till the library shut down for the day.

Some students need to have their own personal copies of books for they learn better when, during their first reading, they are able to highlight selected text and make notes in the margins. They find these of great help during revisions and just before examinations. Most large teaching institutions throughout the country have a variety of photocopying agencies in their environs that specialize in reproducing entire books. They can copy, bind and deliver copies of volumes within hours or, at the most, in a day. A selection of paper, page size and binding is on offer. Texts can be reduced or magnified depending on the student’s need. A book in fine print can, thus, be made available in easy-to-read formats. The student takes out books using his library card, gets them copied and returns the original the next day. He can now highlight, make notes in margins and do whatever else he needs to make his study more efficient and productive.

This unethical practice has resulted in protests from publishers, but to no avail. Many colleges have helped by subscribing each year to agencies enabling individual access by students and faculty to the complete contents of selected books and journals on the internet. The availability of remote access enables students not residing in hostels to use the same facility that is available to those within the campus and its hostels. The restricted selection of available texts and journals is a limitation.

Human ingenuity knows few bounds. The internet features sites offering books free of cost. I am not knowledgeable about them but have been informed that some of them are unscrupulous and offer pirated texts in much the same way as other sites offer pirated feature films. It is, at times, necessary to register on these sites and pay a recurring fee for access to books of your choice. These sites have occasioned discomfort among individuals with a strong sense of propriety. By fetching books from them, are we not depriving authors of their royalty and publishers of their rightful income?

One site that is greatly respected and increasingly helpful is Internet Archive—a non-profit library of free books and more— based in the USA. You can learn about it at https://archive.org/ about/. Its bona fide is evident from the agencies supporting it (Andrew W. Mellon Foundation and National Science Foundation) and its membership of such associations as American Library Association and the Digital Public Library of America. I use this site regularly and have found it especially helpful when studying the history of medicine, literature and ethics. This site does not provide access to contemporary books used in undergraduate and postgraduate medical studies in India.

Recently it has set up https://scholar.archive.org/. ‘This full text search index includes over 25 million research articles and other scholarly documents preserved in the Internet Archive. The collection spans from digitized copies of eighteenth-century journals through the latest Open Access conference proceedings and pre-prints trawled from the World Wide Web.' A quick search made available Covid-19: India is at centre of global vaccine manufacturing, but opacity threatens public trust by Kamala Thiagarajan, BMJ 2021 and Journey from coronavirus pandemic to vaccines by Nagendra Kumar Rai et al., Asian Journal of Pharmaceutical Research and Health Care, 2021. The full texts can be downloaded in seconds as PDF files. Students of literature will also benefit greatly from another respected site—Project Gutenberg (www.gutenberg.org). Over 60 000 books are on offer, free of charge.

I am sure readers of this journal will know of many other ethical sites and hope they will let the rest of us learn about them.

Preserving the Past: Need for one or more Archives of Our Medical Pioneers and Institutes

We are fortunate in having the National Archives in New Delhi, which is ‘the custodian of records of enduring value of the Government of India’. It was established on 11 March 1891 at Calcutta (now Kolkata) as the Imperial Record Department and is an important archival repository. It has a corpus of records, private papers of our respected national leaders, scientists and others; cartographic records and microfilms. These constitute a valuable source of information for scholars, administrators and historians.

We need similar repositories in the field of medicine and medical education in India. We have had a multitude of intellectual giants in the past and continue to have individuals of academic distinction at present in our reputed teaching institutes.

I plead for the establishment of one of more archives that preserve their books, papers, reprints, letters, photographs and other literary and historical artefacts collected by each of them over their lifetimes. I have witnessed with deep sorrow the loss of personal papers and correspondence of Dr Pranjivandas Mehta, an eminent medical historian who had been applauded by Dr Charles Singer and Dr Henry Sigerist. I know of others of equal eminence in other medical fields whose papers and works are scattered and difficult or impossible to trace. Few have had the foresight and perspicacity of Major General Sohan Lal Bhatia, whose books and papers are carefully preserved in the library named after him at St John’s Medical Institute in Bengaluru.

I record with deep sorrow the thoughtlessness of librarians in our historic medical colleges in Kolkata, Chennai and Mumbai. Instead of preserving, digitizing and making available to the world of scholars the historical treasures in their possession, from the 17th century onwards, they have, in many instances, permitted them to disintegrate and disappear. I know of invaluable records on each and every student and staff member in two major medical colleges in Mumbai, one dating to 1845 and the other to 1925, that have been lost forever.

We can build for the future only if we honour our past. Giants such as the great British teachers who set up and developed the first medical schools in our country and their Indian successors who built on their achievements need commemoration. We need to provide free and ready access to their documents and works to present and future students so as to inspire them to similar or greater accomplishments.

We have already lost irretrievably much that is invaluable. We have to act with alacrity if we are to preserve records and prevent their decay and destruction by termites and humans. It is time we start putting together items that students of the future can marvel at: ‘Is this really the pen with which she wrote her epoch-making papers?' or ‘Is this the original manuscript of the text that shook science?' or ‘Is this the set of instruments with which he performed the first operation that is now standard practice worldwide?'

As we embark on this most important task, let us also try and ensure that to serve their purpose—inspire young minds—the archives must be made accessible and free from red tape, easy to search and as near an informational utopia as possible.