MEDICAL EDUCATION AND SOCIAL CULTURE FACTORS
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- MEDICAL EDUCATION AND SOCIAL CULTURE FACTORS
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194
INDIAN JOURNAL OF MEDICAL EDUCATION
I an atmosphere of research, with the result
that the students’ powers of observation
and drawing deductions from such gbservation are not adequately stimulate^; Al
most similar views were expressed 15 years
( later by the Mudaliar Committee about the
! undue importance given to the collec
tion of the mass of detail in the teaching of
anatomy and physiology at the pre-dinical
stagey .
FThe time has come when those who are
ap^ J
concerned with r ■’ical education
take a close look t
aat needs to be
during a limited period of 5 or 6 \
the higher secondary studies and hnt.
students’ knowledge is to be evaluaJ\^
that ‘the student leaves the universit/jjl
his curiosity enhanced and not destroS
with enough general knowledge to asfcg
right questions, and with a
appreciation of method to know how
about finding the answer’,
K'
Medical Education and Socio-Cultural Factors
in Indian Society
■
BY
Dr R. N. Saksena
Directory Institute of Social Sciences, Agra
t in 1847 asserted that ‘medical
and essentially -a
K
Kipnce, and as long as this is not
r y^nised in practice we shall not be able
B ITcmov its benefits and shall have to be
B- Zaried
any
and a sham’1.
U- f Vt analyse this statement we find that it is
T.*. , the
‘j
F Igaed on two basic principles. First,
t teaith of the people is a matter of
t" direct
E •dd concern, and that society has an
E db^ation to protect and assure the health
E if ita members.
Second,
.
. social and economic
.
•oditions
— have an important and in^many
^*.«*-***, crucial impact on. health and
E ftinr* It logically follows as a third
fcirmdple that the steps taken to promote
E redth and to combat disease must be social
Ell well as medical.
E b 1911 Grotjahn published his famous
I
Svziale Pathologic in which he put
E iarwird a number of principles that are
Ejgy^ftKntal for a systematic study of human
CgF***. which laid great emphasis on the
piint of view:2
EK ]' t Hit significance of a disease from a
■J**" Point of view is determined in the
Erf** pk^e by the frequency of occurrence.
is intrinsically
inuiusivaixj
/ 4;
** necessary to know the form,
MP 1 th as the frequency, of the disease.
The etiological relationship between
f^H^hbons and disease may be exin four ways: social conditions (a)
favour a predisposition for a
{b) may themselves cause disease
(c) may transmit the causes of
(d) may influence the course of
only are the origin and causes of
rtcrufined by social factors, but
'
these diseases may in turn exert an influence
on social conditions, particularly through
their outcome.
5. In the case of a disease which is
important from a social viewpoint, it must be
established whether medical treatment can
exert an appreciable influence on its prevalence, and whether such. therapeutic
success as may be achieved is important
from a social point of view.
6. Preventing diseases or influencing
their course by social measures requires
attention to the social and economic environment of the patient.
Gortjahn was conscious of the fact that
many diseases of social importance were
chronic in character, and that a large number
of these were preventible, or could at least
be controlled. He, therefore, strongly ad
vocated the teaching of social hygiene
as an essential part of medical curriculum.
He also emphasised that investigations in
social hygiene would make use of the
methods of statistics, demography, anthro
pology, economics and sociology. Despite
Grotjahn’s insistence on the need for socio
logical analysis of health problems, he could
not move beyond the scientific level of the
period. In Great Britain, as in the United
£States, interest in --j-i —
-j:-:— is ----1social
medicine
a relatively recent phenomenon; while in India
it can be said* to be only in its embryonic
stage.
The British Medical Association in ex
pressing its opinion on the Beveridge Report
remarked: ‘The health of the people depends
primarily upon the social and environmental
conditions under which they live and work,
upon security against fear and want, upon
nutritional standards, upon educational
freemen, Levine and Reeder, Handbook of Medical Sociology (Prentice Hall), P. 36.
a'-1. Soziale Pathologic, Berlin: August Hirschwald Verlag, 1915, pp. 9-18.
195
2
T
-QL. V, APRIL
196 ’INDIAN JOURNAL OF MEDICAL EDUCATION
calories; U.K.: 3,270
2,11^
facilities, and upon facilities for exercise
calories’, and India: 1,880 calories.
leisure’-1 Unemployment and poverty
—.7
•
The problems
problems arising
arising out
out oi
of such
such aa 1^1
1^1
The
produce their adverse effect on health
Indian diet are further aggravated by
through the operation of such factors as
itisfactory housing population explosion in the country, ’fj*
inadequate nutrition, unsat________
.
,
rv,r--------------_______ —.. .1
ot" t’VlA DtACar\4
and clothing and lack of proper medical increase in population,. at *e,
of eight million per year, in itself will requj
care during periods of illness.
a million tons of additional food grains —
Defective nutrition may take two forms year. With an increase of the per
intake of 100 calories per day, India woidj
resulting either from an ill-balanced diet,
require an additional five million tons
which fails to provide the required consti
tuents of food in their proper proportions, or
grains per year2. Even assuming that f
from the energy value of the food being will take --------- ---five years for India
another
insufficient to provide for all the activities achieve
gl-million ton food target of ft
Secon(i Rive Year Plan, consumption in <
of the individual
iiaiAxvxv.—* concerned;
------------- - the former
.
country in the meanwhile will increase 1
constitutes mal-nutrition and the latter
87 million tons, leaving a net deficit of g
under-nourishment Many persons suffer
ing from under-nourishment are also sub
million tons per year.
jects of mal-nutrition. Both these forms of
Thus, the picture that emerges out of |
defective nutrition impair die heal In the nresent
present’ focnf
food crisis
crisis is
is aa dismal
dismal one
one «
«
working capacity of human beings. I
?rmnnts for one of the worst factors in it
for one
of the
factors inJ
fl
Eghtof this argument the diet of an average accounts
acamntejor
one^of
the worst
w
Indian is not only deficient in calon
■
but is also, ill balanced. The per cap,ta
net availability of food grains m
1961 was 16.2 ozs per day. The per c^ta
indicated by the fact that only the mortal!
but
deplorable is that most oi i
preventible diseuf
a » -b •* “i
Table showing number of deaths and death rates {per million of the population)
from different disease?
1960
1959
Disease
Total
Rate
Total
Ri
ICAL EDUCATION AND
I
197
CIO-CULTURAL FACTORS IN INDIAN SOCIETY
. gtriking feature of
table is that a
A number of diseases, which serve as a
1°* ^e2t^-s are gro-psd under such
respiratory diseases’
^jings as
35 ‘fevers
1CVC1B’>, ‘icspiraiury
- Sl
55l’‘otber
offier causes’. This clearly indicates a
r** state of publi.
public -------------health in—
India.
— ..It is
sILidered
j that at least
i
* 50
rn per cent of
_r the
mortality in the country is preventiJkand should, therefore, be prevented1.
JJ7<nd
£
This large amount of preventible suffer-
■
and mortality is also due to the low
I Jvd of environmental sanitation in thea
Anart from widespread
widesnrpad malI gantry- Apart
| gatrition and under-nourishment in the
| ff^ntry, lack of general education and health
I| location
Unration add materially to the difficulty
t if overcoming the indifference with which
I At people tolerate the insanitary conditions
I L-wound them and the large amount of sickr
|! bb
w that prevails. This accounts for an
| ibaonnally high birth rate and equally high
F ■ortality rate, accompanied by a very low
k W^ectation of life at birth in the country,
g • ■ given in the table below :
we are in the realm of illness which can be
identified broadly as psychosomatic. A
second class of events conccfiis those situations in which psychological and social
variables
variables may
may aggravate
aggravate or facilitate the
action of biological or physical disease agents.
These agents combine with the psycho
psycho-
social situation in some manner, perhaps
c a disruptive process,
through an additive or
to bring on illness.. The third category
covers the results of style of life—where
living arrangements, customs, and other
social features may bring the individual into
a situation where he is rendered vulnerable
to disease’.8
Socio-environmental factors determine
how man lives; thus these factors are
intimately related to an individual’s exposure
and
and susceptibility
susceptibility to
to disease.
disease. His
I” group
i
’
L'_
'
1.
membership,
his family
structure,, his work
and his recreation all influence
”_____ where
..I___ Lhe
j
lives, what he eats, and how he sleeps and
exercises, and these in turn determine his
physical and mental state of health.
There is a complex interplay between socioenvironmental factors, social problems, health
The relationships between physical, biconditions, and public health programmes.
r ifagicnl and psycho-social factors in illness Each one may lead to the other in many
| vt intricate and subtle. As Dr Stanley H.
different ways. For example, poor housing
I Bag has remarked: ‘Of first importance are (a physical condition) may lead to
w the growth
| y* situations in which the interaction of of slums (a social problem),
which
in
'
" l turn
** mdividoal with his interpersonal en- increases exposure
h
exposure to
to tuberculosis
tuberculosis (a
(a health
Pr°duces emotional reaction and c__
),which
------------------------condition),
then requires the develop■S? ^}th an accompanying alteration of ment of a preventive and therapeutic measure
ogical balance, beyond the range of (a public health programme). On the other
fluctuations. The end
end. result of hand, certain pubhc
public health programmes,
^nbnued conflict may be irreversible such as venereal disease, become social
changes or chronic disease. Here * problems as they impinge upon the value
I Itdo-psychological Factors in Illness
Table showing Vital Health Statistics^
Cholera
Dysentery and Diarrhoea
...
Fevers
Respiratory diseases
SmallPox ...
Other causes
•••
•••
...
7,696
20.00
18,371
176,541
458.82
179,368
1,458,024
3,789.33
1,457,683
321,632
835.90
320,785
43,662
113.47
34,012
1,537,800
3,996.66
1,529,058
465.
3/
Per thousand of
population
Infant Mortality
Rate
Expectation of Life
at Birth
Birth
Rate
Death
Rate
Male
Female
Male
39.9
27.4
190.0
175.0
32.45
31.66
41.4
29.9
146.76
37.76
^7-49
40.7
21.6
127.68
41.68
42.06
!*l-56
^^l
---------- 161.4—
142.3
i ^re Committee Report, p. 11.
* British Medical Journal, 7th August, 1943.
> Times of India Directory and Year Book, 1963-64, p. 24.
• Times of India Year Book, 1963-64, p. 1221.
ey
Publications Division, Government of India.
• King in Freeman (ed), Handbook of Medical Sociology, p. 101.
Ma,
Female
structure of the community. In such cas
is of greater significance fr<^
moralistic attitudes may .
Xis the social point of view. Illness may
| I
scientific ana>ysu, an- -Oth
-physiological significance, vut it is
j hand treatment of the health pr°b'eI^
* fPsvcho-social phenomenon. Central^
become an area of conflict between medical M^Xpt of etiology is the demonstrati£
.
of
fiut Jh modern complex
systems this is not always possible. In
etiology of illness, the assignment of direct®
technological and highly organised, thereis cause is often difficult, if not imposabk®
a danger of losing sight of the human aspect due to the impact of social enyironm ™
I
of medical care. Health personnel cannot be Hence in the teaching of medicine coi
judged only in terms of training quahfica- butions of sociology have to be gratel
[
tions, proper licensing, and adherence
acknowledged.
educational standards. While all these
f
The Mission of Physician in our Present Society
I
II
BY
Dr P. N. Wahi
Professor of Pathology and Principal^ S.N. Medical College, Agra
ju any developing society the doctor’s role
k ' not only decided by the problems of ill-
9
1
he will be required to deal with, but
by ethical and social obligations confcrred on him by the traditions and the
Gjkural heritage of that social order, and the
Besides, the type of population the doctor
is required to serve, and the changing
I
t^ie S0C^et^ readyto c°nce(^e to health and disease pattern are also to be
considered. Life expectancy has gone up
fc
The preparation for the fulfilment of such from 32years in 1946 to 49 in 1965, while the
B t fnwtion will depend upon the training annual mortality rate has dropped from
B- wceived by him during his medical educa- 27.4 to 16.3 per thousand. We are gradually
S ton.
critical evaluation of the content gaining control over the communicable dis
B
pattern of the teaching programme eases, e.g., small-pox, tuberculosis, malaria,
B imparted in our institutions is necessary if cholera, typhoid etc., and soon the physicians
K- i it felt that the doctors educated in them in this country would be ranged against
fe- falling short of the expectations of society, <z diseases most of which are not fully under
|E Smultaneously, it would also be essential stood, e.g., cancer, coronary artery diseases,
Kr * atudy if the doctors are being provided high blood pressure, and psychosomatic
K akh the optimum conditions for the practice disorders, etc. Industrialisation with its
BW medicine which they would require if consequent urbanisation is causing a popu
are expected to use their scientific lation shift which has to be reckoned. The
■bsowledge to the maximum benefit of the data from the highly industrialised western
£|| flpdation.
countries also point towards a change in
There are thus a number of factors the sex pattern of the society, the mortality
k*76 be considered in determining rate of females is less than the males leading
■gi tMk of a physician in the
2__ Society.. TL_
The t0 a gradually prepondering sex ratio towards
g* and foremost is the health needs of the females. It is therefore pertinent to assume
and the pattern of its social that the future physician will have to practise
About eighty per cent of the medicine in the current social setting which
of this country lives in villages. may be different from the present.
‘
there is 1 doctor for about 6,000
The doctor is indispensable to any advanc
’
rati°
fr°m state to ing society. Ellis has rightly stated: ‘Slow
“e villages cannot claim more than and vigorous investigation must precede
f°r every 30,000 persons while the planned safeguarding of the advances
areas where there is only one
' >WblNL ^CtOr for 50’000 t0 100’000 of modern society, and it is clear that doctors
must be nuin contributors of the accurate
, ere
more than 800 com- information which is needed. They must be
^>^oc^s without primary
^y.res>
more than 400 primary prepared, as in the past, to press most strong
ly by every means at their disposal for that
316 without doctors. This legislation without which the prevention of
loomy situation. In the words
so much disease is impossible. At the same
Minister:
time a doctor must continue to apply preven1!-?
1
?_
1
* no progress JULA
UW medicine at the AW
VA 1/A
AllUal,
in the country tive
level
of the individual.
Our villagers are happy. The by advice, by persuasion, and by contribuP ®bvioi
,us task before our doctors tion to health education in general’.
199
—j'AVglUOO
HI'
I
is to be prepared to serve in the rural
hospital so that they do not suffer for
want of trained medical personnel as
now’.
E:
Bi
VAAV WUllUY
______ —a.
_____ 1______
______ _______
1UVUXV1UV AU VA4V
_!• • 1
ULAV AAAUA V
SCIENTIFIC MEDIC?' CULTURES AND RURAL MEDICINE
. I
The Scientific Medical Cultures and Rural Medicine
BY
(Ti/
Dr Carl E. Taylor
The Johns Hopkins University School of Hygiene & Public Health (Division
of International Health) Baltimore, Md., U.S.A.
AND
Drs Prakash Sangal, Harbans S. Takulia and Joseph D. Alter (Co-authors)Narangwal, Punjab
Ten years ago, a dozen leaders of medical ment at the speed and extent of progro* »
education in India were meeting here in medical education :«
in T«zi:«
India.
Bombay as one of the three committees
None of us who participated in the 195$
planning for the historic 1955 All-India Congress on Medical Education would hitt
Conference on Medical Education. This dared to hope for the tremendous progrtu
particular committee under the co-chairman- which we know now was possible at th*
ship of Drs Vengsarker and Yodh was time. The achievements of your good
responsible for proposing a new curriculum friends who are the medical educatori of
and new teaching methods specifically India are a challenge to the rest of the world.
adapted to the needs of India. It was my The quantitative achievements are impre*.
privilege to represent the academic discipline sive. I know of no other country which hn
of social and preventive medicine. Two so rapidly and massively expanded its medial
new <objectives
’ ’
for medical education in education.
India were accepted. The first obviously
Even more important, however, to me
was the introduction of a preventive orienta have been the qualitative changes. Many
tion into all medical teaching; the second leaders in India and consultants from abroad
was particular emphasis on the need for have expressed concern about the dang*
orientation of doctors to rural needs and of lowered quality of education during th»
rural service. Immediate and active dis period of quantitative expansion. The
cussion centred around the question whether concern is real, and we all know that there
there is, in fact, any such thing as rural have been some necessary sacrifices. Oa
medicine. Some basic scientists on the the other hand, I am increasingly impressed
committee pointed out that one can’t tell with some significant qualitative improve
the liver or kidney of a rural person from ments. The quality of medical education
that of a city person. The differences are should not be measured primarily in tern*
in social, psychological, and organizational of international standards. The best quality
variables. The simplest statement of the of education for India is that which servta
difference is that the whole rural community Indian needs. In spite of occasional expr*
must be considered the patient of the rural sions of fear that Indian degrees will n?1
doctor.
recognised abroad, it has been my expenen®
As indicated by my title, I will try to that wise educators overseas recognise
relate my observations of rural medicine to India should have educational object!'
total medical educational developments in different from the United Kingdom of
India and will conclude with some findings United States and an appropriate
from our Rural Health Research Project. content will only increase their respect for
The fundamental question I will discuss India’s medical education achievem
and the reason for my title is whether there I say this with particular reference
is a basic incompatibilitybetween the emphases which should be stressed a
scientific medical culture and rural medicine. World Congress on Medical Educati0^*
First, let me express my continuing amaze- Delhi next November. Delhi was se ev
364
365
appropriatesph o discuss‘Medical live medicine can do to stimulate interest
hotion
a h actor in Social and Economic in rural medicine as long as they are viewed
I gju**’
neve!0?111 jnt - cause you> as the leaders of by medical students as competing with the
IF 2^1 education in India, have shown other medical school departments? It does
is one °f y°ur major concerns.
not take research to prove the point that
¥
fhe
Qualitative shift in Indian preventive and social medicine is one of the
«
Education is indicated by the many ’ieast glamorous departments in medical
^departments of social and preventive c°heges. Let me show you, however, data
I
Sicme which have been developed. fr?m our research project on the rural orientP Ahbougk these departments have not yet adon °f physicians, which show the ranking
L^blished themselves as being highly given to the various academic disciplines
h:'. gfcfltific, they are demonstrating their by
interns in seven Indian medical
r Mjaal responsibility by pioneering the ccutres. Clinical teachers are the role
^tthlishment of teaching health centres in models for medical, students. It is, therebflth rural and urban areas. I realize fully f°re, particularly incumbent on clinical
these teaching health centres have been teachers to typify in their own behaviour
Ejected to much criticism, and the depart- • 1116 values and attitudes the next generation
ofr preventive
and social medicine too,
students
will> accept
------ ----------------"-----as controlling their
because it is said that they have not had a own behaviour.
auticeable impact.
Rural Health Research Project
My plea is for reasonable patience with
In 1959, when I spent three months
departments of preventive and social medivisiting
approximately 20 departments of
doe. In teaching the community orienta
tion one is undertaking an essentially new preventive and social medicine in all parts
and pioneering effort. It took many centu of India who were developing rural teaching,
ries to develop the present pattern of labora- it was immediately evident that the whole
tonr and ward teaching and we still are not programme was rather seriously backfiring.
really satisfied. It impresses me as being Especially the rural internship seemed
somewhat unreasonable to expect to have to be creating intense antagonism, so
the social medicine and community approach that many interns ended up their experience
efficiently organized and palatable to the saying they were convinced of only one
undergraduate medical student and intern thing, that they were never going back to
on the first attempt. To make this speciality a village again. The Minister for Health
•Qentific there is great need for a great was so concerned about the prospects
that he asked usthe
to study
the problem.
He
Sgision of basic competence in epidemi- indlcated
governinent
was being
indicated that the government was being
a forced more and more forced
into a more
position
andwhere
more into a position where
ne most encouraging development of they were going to have to apply compulsion
years has been the tendency for to doctc
“ in order to get the
• "health
••
doctors
needs
. met.sajdHethat
doctif
orsdocto:
Toners from clinical departments to become of rurali areas
said that
impatient with the efforts of departments and medical educators would
not themselw,es
---------------®ocial and preventive medicine that they ffind the
’ mostrr--r—
—iux for
appropriate
mechanisms
taking over to show how things meeting the health needs of villages, then
o be done. More and more, I find politicians would have to take matters into
^^al teachers participating on a regular their own hands.
7
^‘^cenXV? th16of.teachillg
Afcr two years of the hard preparatory
People
n b
climcal and basic science work that it always seems to take to initiate •
. the
- —„tuony
i u seem
Seie? to
t0 want
Want personally
PC180113!1)^to
to a new research project, we started our fiveme rural heaI
health
centres. There
There is
is an
an year rural health project in 1961. On
. centres.
P°tentiaFfg appreciation of the tremendous sabbaticaUeave^omUiaFvard-andMateF
Wudi^
orTTZT;
—
I for
or research based on
adequately Johns Hopkins my family and I spent a
P°P
u^ations in health centre com'
!hOnitieoP0
^UlatlOI1S
Uving in Narangwal village where the
K-_ ea* I am eencouraged
it has
has teaching health centre of Ludhiana Christian
1ncoura?ed because it
apparent that
that there
there is
is Medical College is located. Out of this
Me ^increasingly
^easmgly apparent
UdeDartmpnmfanriaionJn^n,
- a department of social and preven- pilot project year> we developed a whole
*
A
— a.
a!
1
«
«
AlUH
«■
r
....... -
*» APRIL
------------- — — -
This lack of adequate preparation reflects
t this research are extremely encouraging.
Also of methodologic int^-^st is th
I spite of all the doubts, rural rnships on their total medical education, not just
that our Division of Inti
tional
1° producing a pronounced and oeneficial on their few months of rural internship.
at Johns Hopkins has developed s’^^
^fct. Even though they don’t like to
research in Turkey and Iran. We
In order to ensure better teaching staff
jmit rt, interns are reaiiy better equipped it is recommended that:
translated the battery of tests from
’community and health centre service,
and reproduced another set of
ff^ficant changes have occurred in their
1. The minimum qualifications for
showing similar situations in Turkish**
You will note that the questionnaire Iranian villages so we will soon be abl
"ftudes, with the most important being
teachers of preventive and social
covers the following range of subjects: make international comparisons.
development of a greater sense of
C
medicine include one to two years’
Attitudes of Interns, Professional Oppor
Ljism.
Furthermore,
we
are
closing
in
practical rural experience in ‘com
Let me turn now to the brief descriptiof.
tunities and living conditions in Villages, results.
^fundamental understanding of what it
munity medicine’;
For the last four years we have kZl
and the Rural Teaching Programme. Interns
x
eS
to
be
a
good
rural
doctor
and
still
2. Doctors working in primary health
score on a four point scale the way they the excellent co-operation of the facultie/Z
reinain a member of the scientific medical
centres, which are used for teaching
feel about individual topics. Because of seven co-operating medical schools in
culture.
have training and experience in
your interest in the whole process of educa (All-India Institute, Seth G.S., Bomba*
the clinical and public health
The mimeographed sets of recommendational research, I would like to look in a little Lucknow, Ludhiana, Nagpur, Trivandrum
functions of health centres;
gjns referred to above are available with
more detail at the test that we developed and Vellore). In a wonderful example of a
mpporting data and selected tables from
with the co-operation of the department of contmuingly gracious spirit of co-operatipfi
3. Teaching health centres have addi
djc Rural Health Research Project, Narangsocial psychology at Harvard. This is an we have together been able to gather
tional teaching staff (more than
amounts
of
data
on
all
of
the
graduates
of
ral Khurd, District Ludhiana, Punjab,
adaptation of the TAT or Thematic Apper
usual service staff) provided by the
India. Given below is a summary of perti
ception Test. It is really an effort to find these seven medical colleges in the par
medical college.
three
years.
The
battery
of
tests
was
nent findings and some recommendations
out by more refined projective techniques,
In undergraduate teaching it is recom
©ade by the conference participants after
the attitudes of doctors towards rural service. administered both at the beginning and tht
mended that:
discussion of these preliminary findings.
We have worried some about the name for end of the rural internship by our staff of
~
’ j on preventive and social
this test. Most appropriate would be the seven hard-working Indian Social Scientw
4. Emphasis
aspects of medicine be given from
‘rural attitude test’ but we question the who lived and worked with the interns.
Lack of Interest in P.H.C. Work
the very first year of medical
We expect to have a Rural Health Con
change in initials from TAT to RAT!
The preliminary7 findings of this study
education;
In this test, the interns are asked to look for ference just before the World Conferena
confirm the general impression that young
thirty seconds at a picture, then write a on Medical Education for detailed discussioe
doctors (in this study interns/housemen)
5. Social and preventive medicine be
short story describing what they have seen. of the research findings. With the excellent
ire not interested in primary health centre
integrated with clinical depart
People see different things and the terms help of the All-India Statistical Institute
work. Only 4 per cent showed great interest,
ments and clinicians be involved
they use in description reveal otherwise in Calcutta, we will have a comprehemite
j 22 per cent moderate interest, 35 per cent
in the rural training of medical
_________________
________
_______
_____
____
___
2
_
__
;
______
12.
i
camouflaged attitudes. The scoring manual computer analysis of this material. Some
•light interest and 40 per cent were not
students.
has been extensively tested and validated, of you participated in the Project’s annual
i interested at all.
To
give
more importance to social and
and we can derive from the stories mathema conference last February, at which we pc^
preventive
medicine
it is recommended that:
tical scores for the long list of values on the sented preliminary results which led •
^adequate Preparation for Rural Work
separate page of the mimeographed material. the two sets of recommendations with
Separate
examinations
in Preventive
6.
Only 11 per cent of interns completing
data thatjyou
have been
VTien we started this project, we were all_supporting
rt------- &-----------------------and Social Medicine be made
rural
internships
felt
well
prepared
extremely skeptical about the possible value The recommendations to the governintc*
compulsory. This examination
:
in PHCs; 36 per cent felt that
of such projection tests. I think we have all concentrate on the general problem of
should be at a level equal to that
were moderately well prepared; 54 per
been convinced that not only do the results to make rural health centres decent P**®
of examinations in other clinical
8011
felt
that
they
were
either
not
prepared
lis®
make sense, but the test really does seem to for doctors to work. Priority 1®
®r
.1
subjects.
i * Or were only Poorly PrePare£f f°r rural
probe for a deeper insight into what interns presented of the doctors’ views of thc iW®
asked
about
the
adequacy
of
believe that one gets from standard ques- problems of working in rural health
|
preparation for ten types of medical Some Positive Effects of Rural Intern
and possible ameliorative measures.
tionnaires.
I
th® Sterns ranked primary health
ships
| ^Ve work ninth>
More important to you are the
Before moving on to results, let me add
While the rural internships are not now
that we tried many other educational mendations to medical colleges.
fen evaluating their own abilities, interns having the total desired impact of orienting
research procedures before we settled on include recommendations that studen®
vuiuiuent
preparing doctors for rural work, it is
t
confident io
to pracuse
practise compreueiisivc
comprehensive
rural
and
lower
economic
backgrou®®
’
»
J
this battery of tests. For various’reasons we
- teaco
J
g^unity
care in a rural setting, i.e. mobi- encouraging to note that there are indications
JJ^nunity
have discarded ’the others. We would like given preference in selection, that tea
t u , ^uununity participation, investigate ?f positive effects on the attitudes of some
very much to share our experiences with community medicine have rural expr
L,
Problems, work with public health—interns as given below.
those of you who are interested in similar that social and preventive medi
The following percentages of interns rated
E
ries
and cope with the general manageeducational research because we have learned graded and the clinical teachers p»r
supervision of priroary health their gain in knowledge from the rural post
in
rural
work.
something about what does not work and
work,
ing as either good or very good:
how tests are discarded.
In summarv.
summary, let me sav
say tha*
y|| Ji
battery of tests (which have been handed
out). These have since been widely validat
ed after having been worked over in much
detail by a number of specialists from the
social sciences, psyctiology and education,
as well as the medical disciplines.
■
* — — —
medical cultures and rural medicine
71 per cent ability to learn from practical
Preventive
’ Social
1
369
experience;
health centres durin
ch medical fifth Th
firl"
and clinics departs.
' 3
'
1Viill
*'
uluulce
oi
public
health
686
“
"dmgs
correlate
with
the
to
rate
“
fj^portanee
ot
the active mterest^dnt8 12
69 per cent ability to establish good rela
and
administrative
responsibilities
whkh
int^X"
1
"
5
conditions
™der
tions with villagers;
of the Dean or
S’primary
pihnaO ineamt
‘«ltli centre physicians higher a prim^h^l^°Ui0
t0
“
medical college ^pal
57 per cent ability to get along with
those who had not visited. Interns tin/3
th .?,entre- The fear of getdepartments can be
professional colleagues and auxili
had ne\er
never visited a primary health to imm™; a vdlage ranked second only
involved in co-operat‘‘ecti**
aries, etc.;
trc prior to internship tended to score
studies and in run&^M
56 per cent understanding of socio
Khrr the conditions requiring compulsion
chmcs in the rural healtH’S
economic factors in disease ’
did interns who had made such visits. hA^aCt °f finaiJcial remuneration has lone
ing centres.
I
50 per cent rural life.
^j^y°1^g^^torstOcoraidering'rurd S
jt is recommended that:
9. Small groups of 2-4 interns
I
Interns showing interest in serving in
be given responsibility
I
jj. During
undergraduate
training °b^ ^rTt^
students
shoSd U
b^de73
Stllflente
______ i f
...®,
pnmary health centres and interns coming
comprehensive health'
* I
irom rural backgrounds gained most from
specific villages.
< |
with the working of wdLi^
well-run ^te is information whem inters raXd
the internship and since they are the most
pnmary health centres and, for fomcral remuneration third and job sSy
likely to go into rural service their prepara Influence of Rural and Economic
this purpose, the medical college thS^carTr011? ^^tions influencing
grounds
economic
tion is particularly relevant Those with
should assume responsibility for meir career choices.
®
rural background (1/3 of all interns) felt
Interns coming from a rural har^,.
assisting in the development of
that they were better prepared after rural had more interest in primaryhealthaMHsuch pnmary health centres in
internship while those from urban back than those with urban backgrounds.J
their areas.
14. Provision of drugs, suppUes
grounds indicated no improvement. Those of 10 choices, the primary health edZ ■
from rural background felt that after intern ranked sixth in interest for those withmi 1
equipment in adequate quantity
fHS Service Conditions
ship their ability to apply community meas backgrounds, tenth for those with uflZ I
and quality for all primary health
The
rural
internship
represents
a
crucial
ures for improving health was greater as backgrounds and eighth for those iS I
centres be the first administrative
fm°d in career choice during which doctors
was their skill in management and supervision mixed backgrounds.
c
|
pnonty for State Governments;
■e
particularly
concerned
about
professional
15.' 801116 mechanism be provided for
or primary health centres, ability to work
Interns whose father/guardian’s inrem. 1 ““■derations. In probing tlJconXo^
WiUi public health auxiliary workers and was less than Rs 200 per month repoti^ a
subsidizmg education of primary
W0Uld be Wllling to
ability to mobilize community participation. greater interest in primary health CM I
health centre doctors’ children,
■"em
a
primary
health
centre
it
was
found
In our rural
apperception
al TAT (thematic app
(
service than those from high income £un3bl -3
such as children’s education
the importance attached to maintaining
test) we found that
enthusiastic
idealistic 38 s^own by a gradual decrease in intoM 1 fed professwnal standards without
---------------- kor
/x xuvouauu
allowances or special subsidized
outlook (E) decreased during internship ln primary health centres with increm to
schools;
nrnhakhr indicating
,n4;^ a
, ,
probably
the. development
of father/guardian’s income.
16. Transportation facilities be provided
I prorisio^ ft 1R e 'mPortlulce attached to
more realistic attitudes to rural conditions.
Therefore it is recommended that:
to meet the PHC doctors’ proUnfavourable reference or association to
tessional requirements such as
10. Candidates for medical college
villagers or village life (V- ) sharply decreased
referral of patients and consul
have a rural background Mi ]
while favourable reference or association to
tant visits and that this transport
candidates from familiee wM 1
villagers or village life (V+) increased
be available for his personal use
middle and low income towb |
slightly. This indicates a less unfavourable,
at minimum cost;
be given preference as toog • 11 ’r^t2hthe 111031 salient deficiency of
17. To ensure professional advancement
!t not a more favourable, attitude towards
they satisfy other criteria M 1
rural life after internship.
admission to medical cdhr? i
° j PHC doctors, a common
PH (reference to a public health problem)
11. Stipends be made available in
1
cadre of health and medical
showed an encouraging increase.
service should be established;
18. Pnmary health centre physicians
It is felt, therefore, that thereds no reason
to think that rural internships are total
should be given a guarantee that
12. A programme of vocational gu>®^j
as thA
”
failures.
I
ranked “ghteenth.
alter completing satisfactorily
and counselling about
It is moreover recommended that:
medical service be set uf *****
I i'^togfteC°nd “ 016 Priority listing of
a penod of rural service they
should be focused rnrinly
^11 be given preference for:
7. Rural internship programmes with
I *4; nf J accePtance of rural servicL is
(a) Professional advancement in
rural high schools.
W edUCati0nal faClllties for
major emphasis on community
hospital positions;
health should require three Previous Knowledge of PHCs
4
inorde^Qf-importanee■are
W
Post-graduate
education in
__________ months of working and living-in
nHLTT conditions indicating
"Only 55 per cent of the interns h
,,
India;
rural health centres.
,'*dt0f?bout th611 professional future
a primary health centre before being
.•
fc) Fellowships for study abroad;
8. This programme should involve the to the rural internship. There was a
‘k?*rjt’ ra^k0?1?111*5’^01 Professional advanactive participation of both the tendency among interns who had
for aaked fourt11 and ‘lack of opportuJemain 111 PHC ^ice,
,Or Post-graduate education’ ranked
the doctors should be given
accelerated increments;
26
- Xtel to Mnditi0nS ranked S
I s^ffopir
I
i
I
v, APRIL
INDIAN JOURNAL OF MEDICAL EDU^fTON
19. Those medical students who volun- Staffing Patterns of Prio ry
Centres
* teer for work in rural health
centres should be taken into
The interns’ image of the primary health
government service and their ceritre physicians’ responsibilities and Work
salary started after passing the ing conditions is an important determiu^
final M.B.B.S. examination. of whether they will choose this form
They would then be expected to service. Interns were not bothered abo«
start work in primaiy health the prospect of heavy out-patient loads and
centres after completing their they indicated great reluctance to surrend^
regular internship and the year clinical responsibiiity t0 auxiliaries,
of apprenticeship as reconi
inarie
ever, excessive clinical
loads were recogni^
mended later on;
by
bythe
theparticipants
participantsas
asobstacles
obstaclesto
tothe
the practice
20. Journals and medical publications o
f
overa
ll
community
medicine.
Therefor*
of overall
Therefore
should be routinely provided by
---------was recommended
that:
the government to all PHC
26. Specially trained para-mMirwi
doctors;
workers be provided to look after
21. A special rural allowance of not less
repeat visits of cases referred to
than Rs 150 per month be added
them by the doctor;
to all other allowances now
available for primary health
27. Research should be done on appro
centre doctors;
priate mechanisms for deternwy,
22. Continuous professional stimulation
ing the role of the para-medkri
and guidance be provided
worker in the initial screenh^
through a regular programme of
and simple care of the large
medical meetings and the visits
numbers of minor illnesses dov
of specialists from district hospi
overwhelming the resources of
tals and medical colleges. In
many primary health centres;
fact, it would be most desirable
28. Senior clerical assistants be provided
for each medical college to take
to look after routine repoftfc
responsibility for maintaining
vital statistics, indents, storey
an effective two-way flow of
accounts, etc.;
communication, consultation and
referral with the doctors of all
29. Clear lines of authority at all ieveb
primary health centres in adja
(PHC, Block, District and Di»W
cent regions;
torate) be laid down.
23. Professional growth should be promoted by means of periodic in
It was also recommended that:
service training including semi
Jung to
w primary
—j
30. Prior to posting
nars, refresher courses and visits
doctors
should
centres,
C
_
to taluk and district hospitals
one year of work exp
and medical colleges;
under a senior physician
24. Housing should be provided on a
government hospital so
high-priority basis ' and should
will gain administrative 1
be a model for rural development
and clinical matunty.
in sanitation, living space and in
year should include a ;
being adapted to local and
two to three months ofJclimatic conditions;
tion to rural health
**
additional programme
25. All these incentives should be widely
rural internship.
publicized in medical colleges.
370
gdENTIFIC MEDICAL CULTURES AND RURAL MEDICINE
|
3/1
Table I
Percentage distribution of interns by the degree of agreement with various conditions for
^rving in primary health centre, before and after the rural internship and also by the direction of
~t aft**1, th® internship (reference period 1964).
N
Direction of change
Low Equal High N
5
7
1.55
1.68
483
447
17
58
26
432
• j I would accept a primary health B 43 17’ 25 15
centre job only if my family A 33 19 28 20
were in urgent need of financial
help
2.13
2.35
484
447
19
50
31
432
jj I would go only if legally required B 39 13 22 25
for one or two years before A 31 15 26 28
registration
2.34
2.52
482
447
22
48
31
432
74 I would work in a primary health B 45 131 21 20
centre only if I cannot find work A 38 17 23 22
elsewhere
2.17
2.28
483
447
21
50
29
431
7J I would work in a primary health B 47 16 20 17
centre if this was the only way A 42 17 27 15
of advancement in government
service
2.07
2.15
484
447
24
48
28
432
l.i I would work under present condi-B 27 11 29 33
tions if I knew I would not be A 22 17 29 32
stuck in village for life
2.67
2.72
484
446
24
49
27
431
7.7 I would go only if permitted to B 35 13 31 21
live in a nearby city
A 30 18 33 20
2.38
2.43
484
447
24
50
26
432
7.8 I would go if there was some im- B 7
provement in both professional A 11
standards and living conditions
7 31 55
8 32 50
3.33
3.21
484
446
27
53
20
431
7-9 I would go if a liberal allowance B 35
and provision for personal com- A 28
forts were provided but without
significant improvement in pre
sent professional opportunities
110 I would go if facilities for main- B 19
taining good quality professional A 16
•tandards were provided and
without particular regard for
improved living conditions
16 36 13
25 34 13
2.27
2.31
484
446
31
42
27
431
18 37 26
23 39 23
2.71
2.69
484
447
33
37
30
432
1.60
1.47
484
446
19
67
13
431
1A
I
te*
w
*
1
I
:
Agreement Scale
12 3 4
Mean
Conditions
I would leave medical practice B 66 18 10
rather than go to rural areas ... A 60 20 13
I am willing to sacrifice both per- B 67 13 13
•onal and professional con- A 71 15 10
■iderations indefinitely
7
4
Do you think you might change B 57 43
your opinion if you knew more A 37 63
F---------- about—primary health—centre------------Work?
478
446
l^Disagree, 2—Partially disagree, 3—Partially agree, 4—Agree, B = Before, A = After.
372
INDIAN JOURNAL OF MEDICAL EDUCATION
VOL. V, APRn
SCIENTIFIC MF
1966
Table II
Percentage distribution of interns by the degree of importance of various factors ii unfavourably m serving m a primary health centre, before and after the rural intern^
-’ni
U1P axjJ
also by the direction of change after the internship.
Factors
9.1
9.2
9.3
9.4
9.5
9.6
9.7
9.8
Mean
N
9 28 53
11 31 53
3.23
3.30
483
451
21
57
22
Problems with personal grooming B 30
and appearance.
A 24
34
38
2.15
2.23
481
450
24
46
30
Unsuitable Housing.
B 6 20 40 33
A 6 19 45 30
Lack of opportunities for profes- B 2
sional advancement.
A 2
10 32 55
10 37 51
B 2
A 2
Inadequate equipment.
Objections of wife/husband (even B 25
if if
unmarried).
unmarried).
A 25
Objections of other
members.
9
8
9 33 56
9 39 50
23
26
32 20
28 21
f a m i 1 y B 25 28 27 10
A 27 35 26 12
Inadequate primary health centre B 12 32 35 21
buildings.
A 12 30 43 16
3.00
2.99
3.40
3.37
3.43
3.38
2.46
2.44
2.13
2.23
2.64
2.63
483
451
23
480
53
25
?
21
63
17
23
55
22
482
451
Fear for personal safety.
437
K25
27
45
29
22
31
47
31
40
30
437
436
■I
W6
■w
■I
B = Before ;
15 36 46
14 39 44
3.26
3.24
481
451
24
51
24
437
9.11
Inadequate drugs and supplies.
5 29 66
5 27 68
3.60
3.61
483
451
14
68
18
437
9.12
Difficulty of access to libraries B 4 14 38 44
reference materials, and re- A 4 15 42 39
search facilities.
3.22
3.16
483
449
29
48
23
413
9.13
Lack of social activities and re- B 9 25 43 23
creational facilities.
A 9 31 39 21
2.80
2.71
483
449
31
47
22
435
SB
9.14
Not enough pay.
B 12 13 34 41
A 8 17 35 40
483
449
20
56
21
43$
::
3.04
3.08
9.15
Poor quality
assistants.
professionals 6 22 42 30
A 4 23 45 27
2.95
2.97
483
449
26
47
27
9.16
Lack of variety in clinical work. B 13
23
2.70
2.80
482
450
25
41
35
15
I
1
63
57
3.53
3.44
482
450
22
63
47
46
23
24
2.85
2.89
482
450
24
52
4
Involvement in medicolegal
437
Lack of transportation facilities B 2
and communication with urban A 3
areas.
8 28
Political interference.
U7 Living in a village.
9.10
10 31
Too few patients.
-
435
E
450
481
450
9J3
437
B 9 20
A 6 23
28
44
28
436
20 19 43
17 20 47
2.87
2.98
482
446
19
52
29
433
4
5
1.70
.1.80
482
451
19
55
26
437
B 22 25 30 24
A 20 26 32 22
2.56
2.57
481
451
28
43
29
437
B 40 23 £2
22 15
A 44 22 22
-2 11
2.13
2.01
481
450
30
47
23
436
B 39 24 20
A 35 25 26
16
14
2.14
2.20
482
450
25
48
27
436
19 33
19 37
2.55
2.68
481
451
19
51
30
437
work. B 28 29 2
25’ 18
A 25 25 32
-2 17
2.31
2.42
483
451
23
48
30
437
B 40 29 18 13
A 34 22 31 12
2.05
2.22
328
305
19
50
31
293
Too many patients.
437
21
L.vk of COusuiivuia.
482
450
B-
43$
43?
43?
♦5?
1
B 12
A 10
B 56 23 ..
17
A 52 21 22
4*
48
>.18
2.72
2.70
■
31
Lack of educational facilities for B 1
children.
A 2
27 37 23
30 39 21
^122 Fear of losing clinical skill.
482
449
483
451
aw
437
482
451
9.17
Direction c?
of change
Low Equal High
i N
Being supervised by r —
non^-medical^ B 18
persons
such as BJ°Ck
Officer^
. - -3
ment Officers.
3.22
3.06
27 37
N
fe ■
Lack of medical meetings and B 4 15 36 45
stimulating
professional A 4 20 41 35
contacts.
---------------------------------------------- A 9 22 48 20
Mean
Health hazards for family.
9-9
B
A 1
Importance Scale
12 3 4
I' • <M9
BIOS
Direction of chriange
Low Equal High
Lack of opportunity for post- B 10
graduate education.
A 6
27
31
Factors
KSrLL-____________________
(Reference Period 1964)
Importance Scale
12
3 4
373
ir
i
^L CULTURES AND RURAL MEDICINE
B 30
A 24
18
20
AA7^fter;.
I1=Nc
— Not important;
3 - Moderately important
vjry in-.n2,Z^htIy imP°»ant;
;
xu.'.xz
Folk-Medicine and Modern Medicine in Peasant
Society—Its Relevance to Medical Education
BY
Dr D. V. Subba Reddy
Upgraded Department of History of Medicine, ■
Director and Professor,
Osmania Medical College, Hyderabad, A.P.
Medicine and Society
on—‘Evolution of
V7S1C1
MVgAXAo his lectures
-------Osler begins
Medicine’ with the following philosophical
observuduiis.
observations. ‘Medicine arose out of the
There is also a great inequality in this
pect
:ct between the
me town and
mxd country,
county,betwej
r
• <1
M/wratKr nori (11
the wcaiuiAj
wealthy
and the
impoverished
dist
—
-r - • vusifw
and between the different social classes’^
ot
Contemporary society is not of the m
uniform or universal pattern even in
West or in the East or in any country, (
to help others and whatever is done with this or countryside. Today, in certain parti
end, must be called medicine’. ‘The first
the world, there are not only abong
lessons came to primitive man by little expe tribes with a culture resembling that
riences crystallised into useful knowledge . the very primitive societies but also pea
‘No society, so primitive is without some societies, which resemble the pastoral
evidence of ihe existence of healing art,
agricultural societies, of two thousand y
which grew with its growth and became ago. In advanced countries and m IB
part of the fabric of its organisation.
areas, ^
there --^triaHsed
are industrialised or
or capit
Hughes mentions the set of minimum . societies. Another classification uses
conditions necessary for coherence ot a terms developed society and develop
deve 0|
society’which he calls‘functional requisites . society
-etY an
d under-developed
society, j
and
under-develo_
Such are adequate economic base, education common parlance
rlance we
we hear
hear of
of upper
upper dll
cl®
of the members, pattern of communication the middle classes and the lower
and division of roles, shared goals, etc. One The problems
problems of
of health
health and
and medical?
medicah
of the primary requisites of society is the in these different strata
ociety or
strata of
of ssociety
or sed
sea
active
live pursuit and
ana maintenance of
01 health.
of population naturally
natUrally differ from
froc^
The attitudes of Society, towards health, sectf0^ t0 another and may requite
medicine and the sick man and its valuation of Gaining and orientation ot thg
of health and disease, have changed a great g^dents and to provide the mara
deal in the course of history. .Today, benefits t0 these different sectors ot »
developed societies care for the indigent
sick, for practical reasons also, realising that
5
society is seriously handicapped by having Folk-Medicine
Folk-Lore:
Is
defined
as
tra
sick members and that the diseased group
is a menace to the whole population. This customs
--------- and superstitions of the u
is the modern concept of welfare state and class of civilised nations,
lore includes the material as we
the socialistic pattern of society.
intellectual culture of the backwaro.
Rene Sand comments that ‘in spite of the
efforts that have been made to put medical in the civilised society. These are
care within the reach of all, its quantity and by traditions and a desire to carry .g
-change, what one’s parents and pr
quality are still far from evenly distributed
i
txs
__
,
services available to different income groups.
-«<
. By usao
masses of the people do not be 0
206
ui rmUMUM 1 MJbitli
B
tion, which tow
over them, and
r
is never
th6*1
/n creati°n.
| ^y^Medicine'> is a specialised part of
^t4orc.
UcKenrie points out, ‘The thoughts
• Cfancy (of mankind) not infrequently
' * 11X1 on into manhood (of the race)’,
ideas and practices form a
f **cKof popular medical folk-lore. This
f tA-.tnedicine is to be distinguished and
JjLentiated from what is called ‘official
historical” or “academic”) medicine’, that
’^jgy, medicine of the educated people
F L of the recognised schools and authors
I Zntr the earliest times to the present day and
I l^rtsented by various literary records.
XU/
progress of civilization, great changes in
society, political revolutions and educational
reforms. There is, however, one interesting
undisputed fact that folk-medicine is a
prominent reservoir of empirical knowledge
based on experience and traditions. Some
original minds have drawn upon this folk
medicine, borrowed ideas and developed
new discoveries for the benefit of mankind
and these have now been included in the
armamentarium of modern medicine. ‘There
is a constant two-way inter-change between
scientific medicine and folk-medicine’.
Folk-medicine or anthropological medicine,
as* Prof. Entralgo calls it, exists even today
in every part of the world including the most
highly developed nations. Professor SudI *folk-Medicine’ writes Sigerist ‘is a tiig
I
hoff mentions that the healing customs of
| ^dge-podge in which primitive lore is Teutons include even to this day some folk
: y^ded with reminiscences of uses and medicine. Professor Sigerist states that
r
°f academic medicine of the past’. some of the old beliefs and practices still
I The essence of folk-medicine where it has persist, even today, not only in Africa but in
element or a Europe and America, particularly among the
I. i»ystiical element or .empirical
.
; of both, 2is a recognition
o._12 of the peasant population where the patient is
J >abination
action of the drug, animal, vegetable
treated by his relatives or treats himself
e1jpitive
-.
_
~
2. MostJ of these are 2
according to folk-medicine, pure and simple,
P < mineral.
based on
ttperience of groups of individuals suffering The relative proportion of folk-medicine
and modem medicine vary today from
rftim certain ailments.
country to country and from society to
n- Xalk Medicine may take many forms:
society, according to the medico-historical,
fe Amulets, charms, incantations, fumiga- socio-economic and cultural patterns and
: fcfe. King’s touch orthe healing by Royal the changing values of the people, and the
snake worship, treatment of snake- spread of modern science among the common
, taboos, temple worship, healing wells, people.
*, drugs, are some.
Newman states that ‘folk-lore is ultimately
Wgdon appears to consider Indigenous rational’ and cites the opinion of Allbutt,
of Medicine as folk-medicine. ‘it is the beginning of the science and art of
acholars including Prof. Sigerist do medicine’. Newman also quotes Malinowski
^tiude Ayurveda and Unani in folk- that .‘the -study v*
of folk-lore and folk* ^°tigdon quotes Dr Saunders of -------------medicine’ can
instruct
-----------—£ us in how to graft a
new idea on the old one without destroying
■x-medicine is neither precise nor what is good and sound in it and can be
rooteti in people not know- used fully in the understanding of both
requires only occasional success preventive medicine and the various kinds
.tain its vigour
’.... ‘Folk -Medicine of medical treatments and methods for
„
•^affairly
•; well-organised
.._2
and fairly prevention of disease’.
" ‘ ’ . ... ‘Folk
°f medicine
^nourishes because it is a functional Modem Medicine
part of the whole culture and
Osler in his ‘Evolution of Modem Medicine’
► tn^ enakles members of a cultural
takes the readers on an aeroplane flight
Ik y^t their health needs _as they over the progress of medicine through the
ages. He traces the slow painful character
.explanations have been given of of the evolution of medicine from the frarthrough ages, in spite of the some superstitious mental complex of
I
”0
C/>
CP
208
INDIAN JOURNAL
V0L‘ V»
OF MEDICAL EDUCATION
primitive man v.— — —
,
~
gods and disease demons to the ideal or a
dear-eyed rationaUsm. The chapter on
Sts*
££ 1’““^
not a natural but a social science and isZlI
s is to keep men adjusted to their
' ’ useful membfr^sl
bXhich time certain objective features of the society and ^ readjust them
disease were known. The art of careful prevention has broken down. pe c
observation was cultivated, many empirical will have to be
remedies had been discovered, the coarse and will have to be teachers and **
structure of man’s body has been well worked
XXL* a
.
out and
a tvzw. ----- Q----machinery worked. Then, m
the body
1
xuux* century, came? the advances relating to Peasant Society
18th
Peasants: According to the New
the nature of disease, its seat and its cause.
Dictionary,
the word ‘peasant’ is dS
The early decades of the 19th century saw
the rise of anatomico-pathological schools of from an old French word meaning a divii
dicine which is turn gave birth to modern of ^countty andto
j
me
clinical medicine. The progress of scientific lives in a country and works on a |
medicine became impressive by the end of the either as a small farmer or labourer. J
name is also applied
to
any
rustic of ;
—* «
*
•
19th century.
working ma»a.
class. Webster
s aNew
.
.
worKiug
TivLiQw. ’»
.w.. English!
Shryock, who is a general historian, inter- tion
peasant1 as
____ Jdescribes
___ l’_
■the
’ ------as the
the |tj
ested in medicine and who realises that oi
•• cxuxavx
• .
« x—
meJSuu,
»»
jj.-ietor <
of the
soil,
either
as »a-----small
proprietorj
history of medicine is an essential part of labourer. Sometimes it is also used tog
to |
history as a whole, describes in his book to
to aa basefellow or a boor. The i
‘W*tik7|yxxx<.xxv
Development of Modem Medicine, ,the posiuon,
position, behaviour
DCliaviwvxx cxxxu
and manners of ped
major aspects of medicai development against
considered to be distinctive,
the background of intellectual and social
Peasant Society: Gordon Childe skfl
history in general. He also describes the the origin and characters of the Pfl
of modern medicine between Society. ‘With the invention of the pg
IgOOMidlssb and thetriumphs
ofmodei
___ ;___________
' :rn
5000 years ago and the harnessing of a
medicine, between 1870 ande 1900 and to the plough, fanning changed frog
sketches its further progress m the 20th. cultivation to agriculture. Man bag
century, including some of the consequences till the fields. The hunters gradualijl
of the new discoveries and closes with the up hunting and devoted themselves CM
practice of medicine in a changing society ing and fishing’. ‘The great
between 1880 and 1930.
people, peasants, farmers and fisberM
Galdston has graphically stated the pre supplied the foodstuff to maintain1
sent approach to medicine. ‘The disordersdisorders geives and the whole economy ANRI
uuu.
—inot
and diseases now d
dominant
are not due to exceedingly. The producers had
specific pathogens, but rather to economic, for
pUrchase of other things.
‘ d, pulldual,
loratjon of land reclaimed from sw^P
social,
political, and
an< cultural factors. To meet
challenge of this patho-demography, deserts was yielding unprecedented^
there is need for all accumulated kknowledge
Je wheat, and other foodstuff. <
But in collected from all the store-houses in^
that modem science provides us. ”
uwa*
t^ie
could be distributed all over the vang
addition,
there __
is________
need—for some
Hippocratic
orientation.
In
other
words,
even the
secured a more
jyu<,xauv
—
*11
CVC11
nxv masses ------------------* *
«
_____ ^.*4.
nr»ntnmira 1 iv
need« to
t anj more
housing .
mnrft salubrious housing
™
1AJ know man not only anatomically,
physiologically, and psychologically, but
MEDICINE IN PEASANT
also anthropologically, for medicine wll be
increasingly coiSronted by pathogemc forces
that are ecological, social and cultural in Medicine in the 18th Cent
U.S.A. Shryock describes thej
nature’.
itury io *3
Professor Sigerist has repeatedly stressed medicine in the 18th cent
ing
society,
almost
a
peasant
«
that medicine is basically a social science
Jr
WO
JKJLXXJTW
-- ------ J
a
- * '
••
Bp-
lax X Xi/WAxti 1 - <5U'-lt 1 *
E.jvfedical men ' rural areas lacked
H
but were prac< d men who learned
E £ffC^Lrience. Licensing regulations were
^Jforced to exclude folk-healers, quacks
E
cru3rlatans. Most eighteenth century'
B
parently dosed themselves and conK'*LtPp«ctitioners only when alarmed.
F l*jOsver the income, the more likely was
I & to be the case.
E
1 ’S
Upto the time of the Revolution,
f
years ago, the common people had
| •^\rJscen a physician, but were treated by
*\*Xine-men, witch-doctors, or clerks,
I
and monks using a type of primitive
medicine, a combination of empirical
yj^wiedge of magical rites and religious
f ‘d*£*(^ina. Before the revolution in 1949, the
I Ka^nts depended only on folk-medicine
| ^traditional practitioners. Medical care
rural areas was virtually non-existent.
I Tbe farm population could get only water
I wf»ply and vegetables, polluted by excreta.
The peasants suffered from transmission of
f frriitr through fecal anal route and intestinal
i wwites like hook-worm were common.
E: Mdaria, Filaria, Kala-azar were epidemics
E > •one areas.
Ihm Peasant Society resist Modern
Medicine?
There has been some discussion whether
non-literate societies show any
1innovation on account of their
beliefs.
Ix-Uguvo
uuo
Hughes wxxtxavuwo
contradicts this
...
cases of resistance to innoin many places in the world today,
c ttceedingly high prevalence of sickm conjunction with the demonseffectiveness of modem medicine,
to create some of the strongest
f°r change in the direction of new
cultures. Once people refuse to
SK|X
inevitability of disease and early
along with this, have some image
pr demonstrated effectiveness
^medicine, forces for basic changes
nfe are set in motion.
■teLin India:
_ Some of the
ij^. Questions relating to health and
in rural areas in India have
g^^uealt with in the learned addresses
g
Ung of World Medical Association
tAJ
in Delhi. The thought-provoking paper of
the late Raj Kumari Amrit Kaur on Educa
tion and its Impact on Rural Health’, the
valuable suggestions of Dr Amir Chand on
iHealth Care in Kura! Areas' and the compre
hensive presentation of Dr K. N. Rao on
‘Public Health in Rural Communities’ and
the editorial in J.I.MA commenting on
these papers, are a mine of information for
the administrator and teacher. Some of
these are pertinent and applicable to the
health care and medical aid in a peasant
society.
But so far, no special reports have
appeared in India and no special studies have
been conducted to collect data on the socio
economic conditions of the peasants and
farmers with particular reference to the level
of health, cost of medical care, patterns of
disease, availability or non-availability of any
kind of medical aid with a view to identify
their problems, conduct intensive inves
tigations and to make necessary modifications
or provisions in the care or in the medical
curriculum to meet the needs of the peasant
society.
Lt. Col. Amir Chand recently published
an article on ‘The Role of Health in Our
Agronomy’ and urged that education in
medicine and agriculture need to be co
ordinated. He mentions the hazards, dan
gers and diseases likely to be contracted
from animals, from insecticides and urges
better farming by ensuring better health
of the peasants. He suggests the training
vx
ovivuuow xxx
vv/vauMxxax
of multi-purpose
scientists
in vocational
aspects of agriculture, health and sociology
to give guidance to the farmers.
Ignorant, illiterate and indigent peasant
cannot approach the practitioner of modern
medicine or even those of Indian Systems of
Medicine. He consults the compounders,
ward-boys, and quacks.
KALEIDOSCOPIC PATTERNS OF
MEDICINE IN INDIAN SOCIETY
Medical folk-lore in India is the vast
background against which stand out a few
bright patches here and there consisting of
the official systems of medicine like Ayurveda, Unani, Modern Medicine including
Homeopathy, etc. Traditions persist tena
ciously through centuries in India and many
6
--- »
I$LJgl fe? '
and ModeRN medicine in peasant society
are still alive in many ways. The folk-lore hospitals in the district and taluq head
211
I®
01 reIuct
due to traditional
‘is a hodge-podge in which ancient, medieval ters and to the inert
g number of
11
developments
—
political,
social
and
and modem views are inextricably mixed, medical practitioners of modern medP^'W W S^rvati8111 or psychological fears. The
economic. In addition to folk
factors that matter are ignorance,
Public Health and Preventive Medicine----------------------------------------------------- ij?
medicine the Indigenous Svstemc
|
rjfpynsib^
of awareness of the
hi India were essentially social practices Factors which Deter Utilisation
or Medicine and the Modern
f Zefits of modem medicine, and the econenshrined in the laws of the land from
Modem Medicine
bcientific Medicine are available to
B
Zc
disability
to
meet
the
cost
of
modem
the time of Manu and Kautilya. The
Hodgdon describes the various psvchnl fl
the common man in all parts of the
| medical care in a far off city or in a private
society functioned on the strength of tradi- ca] and major problems facing the m
Hl
country
except in the remote villages
I’ dfcwctions and customs, backed by moral compul- profession in developing countries like
and the hill tracts and forest areas.
sion and religious motives or sanctions The first is the lack of facilities for tran* '' I
RELEVANCE to medical
Medical education in India should
rather than by any set of rules and regula- and communication, producing physical ' 9
take into consideration the com
EDUCATION
tions. It has been suggested that modem sociological isolation which retard aJS - 8
plexities of the Indian situation,
(Q Recent World Trends in Medical
principles of health can best be assimilated change along with a lack of awareness arn**
geographical,
social, economic and
Education
only if they are m some measure attuned to the rural folk of the advantage of mod^ I
cultural as well as the needs of the
(<) There should be provision for teach
the age-old beliefs and practices of the society, medicine and therefore, not demanding? 3
various segments of society and
ing the psychology of the lay mind
should be oriented to the conditions
In ancient and medieval India, there was People depending on indigenous systems
to enable the doctor to appreciate
of life and work which vary from
a system of medicine, known as Ayurveda, medicine feel European medicine is alic*
the patient’s point of view and to
place to place.
Professor Sigerist has described how it is t° their beliefs, customs and experipn^t ~
obtain an insight into the working
(b) The Bhore Committee and the Health
rooted in religious and philosophical tradi- The second major problem is integrafii^W
of
the mind of the patient.
tions of the country and how nationalism die indigenous systems of medicine with
Survey and Planning Committee
great body of scientific medical knowlede^S?!
(b) Social sciences should be taught to
have recommended that adequate
has backed this system of medicine.
make him realise that medical
public.heal th orientation should be
He has also drawn a graph picture of the Hodgdon points out the difficulties in inwBpi
education is for the service of the
given in the training of the basic
practitioners of modern medicine trained, grating the Indigenous Systems of Medich^H
society. Medicine is not a means
doctor. They also recommended
through the English medium, as a highly with Modern Medicine. These systnwrB
of becoming rich but an opporsome arrangements for the training
trained technician ignorant of the real goal have a profound hold on villagers, and
tunity for service to the needy.
of the student in rural centres
of medicine, practising a primitive type of systems lie also embedded in a social «n4 iM
The student should be given a
situated near the medical colleges
modem medicine that is hardly likely to de psychological matrix as well as a med«s‘5 '
f
broad view of illness and its control
or that the students should be
monstrate the superiority of Western medi one. These systems are interested in
based on a socio-economic and
taken by the teachers of Preventive
cine and, due to his poor salary, forced to val, and constitute a pressure group witM|iW: s
environmental influences and he
and Social Medicine to the neigh
r
£
make a little money through modern doctor’s society. The third major problem
r
must be able to correhte clinical
bouring villages on certain days of
private practice. The villager, too poor to pay the profession and, in many ways, the
conditions with environmental and
the week to acquaint them with
for his services or imported drugs, seeks the difficult one, is the problem of health edofl#-M
socio-economic conditions, The
rural conditions. It is also suggested
help of the indigenous practitioner, who is tion.
teaching and training in the
that during the period of house
a villager, whose native herbs are cheap and
Max Weber, an eminent sociologist II
school should orient him towards
manship, the professors of clinical
whose ideas conform to those of the patient, stated that ‘other-worldly’ orientation J
multiple factors’ (such as physical,
subjects and of Preventive and
Besides Ayurveda, there is in India the Hindu-Buddhist religious tradition of
social domestic, mental, environSocial Medicine should take the
Unani system of medicine, which attained and its consequent development of the cw
housemen to iui<u
rural xuemcai
medical centres,
centres.
which result in disease.
—
popularity in some kingdoms during the system offer fundamental constraints on w
to tbltUde?t Sh°uld bie “^oduced (Hi) Modifications of the curriculum
later medieval period in India, and continues development of modern sciences. **w
surround:"18
for the
eminent
to be popular in certain regions and certain are
*”■“ other equally
h- —
• * sociologists w
think that a number of trends in
may
d0Ct°r
Basic Doctor for India
sections of the population.
Hn -dea °f natural
(a) The
The student
student should k.
be taught to look,
The third phase of medicine in India is tradition are favourable to the growth j
and proximate cause of
sciences
including
medicine.
the advent of European Medicine from the
at modern medicine from the
illness in that environment.
16th century through Portugese, Dutch, cognise the fact of the existence of
perspective of history, as a result
Pr) The
bSical student should be taught
of a long development and as a
French and English medical officers. It values in the religious traditions of
/aun economics and medical
dynamic process. Professor Sigeis, therefore, only from the beginning of the
From preliminary enquiries
^onomira. There should be a
19th century with the extension of British questionnaires sent out, one is inc
inclilhjj
fljg^
nst recommended that the medical
ethi‘nstruction in medical
student in. India should have
knowfl
power and territories in India, that the conclude that wherever modem kno**
ship ete d doctor"Patient relation
o-----x_---------------------------up-to-date
_r______ ___
__ _ of medical I
British medicine---began
to _spread
its influence and
methods
instruction in history of medicine
including history of Ayurveda,
beyond the circle of British soldiers and public health and other social welfare*
welfare ”
’
Unam and Modem Medicine.
civilians to the aristocratic and educated vities were provided, the peasant bis1 *
S.
in^ ce to Medical Education in
upper class in cities and big towns has not been slow in accepting ®
*5
($) Health Survey and Planning Com
and gradually became more widespread and appreciating them and asking foT JS]
mittee have recommended that
education in India today
is
popular through civil dispensaries and Therefore, there is no evidence
Aperts on Ayurveda and Unani
e result of many historical
should be associated with the
■
-212
With the heln of health education
(b) Students wh- ^e to be the futu,e ig
he must 1
trained to carry
doctors <
he peasant
8°cie^ "S
he
society
Departments of Pharmacology an
on mass campaigns like vaccina
should be recruited trom
8
Therapeutics and participat
tion against Small-Pox, immunisa
S
the natives
natives of
of the
the rural
rural areas
areas 2
Jf
teaching and research programmes
tion jjgainst Tuberculosis or cam
foX investigation of mdigenous
beingr done ai
at pi«^xxi
pr^ent m RUS6i ifi
paigns against vectors of disease
||| I
The•.'student
SVIXVXVXxv may
----- J be selected
and
environmental insanitation.
drugs.
._j
Uxr
Panrk«.._.
nominated
by th**
the Pancha^h
All these can be incorporated in the
of Zilla Parishads and
and suppoJ^J
suppon^-|si
teaching of Public Health and
during his education on conditioJg
Preventive and Social Medicine.
‘
^ter
training
he
serves
ijj||
for Rural Areas in India
that after training he serves
people of the area for a spe<fc|
* special courses and training in
The medical centre where instniction
fled term. The student must be net |
v'
Agricultural Medicine
1a)
is given for the training of the
fotSe doctors of_ the,peasants
Ae “peasants
less than
U.1OXX 20
X-W years
J -y- ofjge
« J r and num
T-a H
U) A recent W.H.O. report says ‘Occuhave lived and worked for son*
Should be located in a purely rural
K
pational Health in Agriculture’ is a
years in the peasant society anjrij,
aai
at
least
in
a
senurelatively new concept. A decade
atmosphere or
sem
must be ptysi'?UL„robJU2l^^
rural
atmosphere where th
or two ago, occupational health was
rural atmosphere
vironment will approximate to the
mentally mature before admissio!v4’
generally referred to as ‘industrial
studied not o*:|
He should have sturied
3o
C^ "into
conditions
into-Which
which he enters
hygiene’ or ‘industrial health*.
conmuoi
physical and biological
biologiral sciencrf
Xr to training-that
so thatthe
thestudent
student
Farming is definitely an industry,
but must have practical fowled,®
foliar with
with and
and accust
accustwill be familiar
and from the standpoint of capital
^ed to the languages of thei people
and beha
vMg^
of humanities, social
soaal^
behavwi
investment and number of persons
ral sciences (Sociology, Histoflg
employed may be termed ‘big
and their expressions and reactoand
etc.)]
Economics
and
Psychology,
etc.)
W
business’. The environment of the
tions, have a foretaste of the kind
selection, greater
sho«
_ ____ that may suddenly
selection,
greater attention
u..
agricultural worker involves greater
of problems
be
paid
to
the
background
of
M
and
develop
the
resourcebe
paid
to
1
exposure to infections and parasitic
arise, i
student’s aptitude, mottvattonig
diseases than urban surroundings,
fulness to
- meet the exigencies of the
UXWX^l
Char3CtW
other moral traits
-• j to isolated
the close contact of the agricultural
situation, travelling
Susruta
m
which Charaka
Cxxxxx.— and
.
by primitive
workers with animals and of their
hamlets or farms
f,
commended for ,_nledlC^, .
’
to
attend
to
products with contaminated soil,
modes of transport
and which are demanded by
emergencies
water and air plus the hazards of
emergencies or tackle community
Sth problems. If such ideal
Hippocratic oath.
numerous insects and arthropods
rural location of the medical college
,
x
Trnin
ine in Community
increase the likelihood of his
rural loca
student
The future doctor should also
is not possible and the student
contracting diseases caused by
has to learn in hospitals situated
to make use of community
viruses, rickettsia, bacteria, fungi
^mwns not only his v^ons
help and to stimulate suchJWg
and parasitic agents.
^Ip. He must also know
of his term ot
but also a part of
| W In the report on ‘Occupational Health
^truction should be in the rural
approach villagers, find theb^Wg
Problems in Agriculture’, the
common interest, keep
dispensaries and hospitals among
W.H.O. Committee recommended
theagricultural population so that ,
with them, win their c
appropriate instructions in the
deal with them as equals andlfll||
he may understand and analyse th
subject at the under-graduate level.
he “th problems of the peasan
vate the villager town-ds p^^^
‘The teaching should include
and community deve^Sjsociety and evolve methods, fo
general
knowledge of the agricultu
Sent of the diseases or attempt
Medical relief work
ral environment and its impact on
JXnts
will
facilitate
^ch^;
preventive measures. In short he
the health of the population with
E
standing and secure Ae^^
must be ‘problem oriented and
special emphasis on the type of
co-operation and
apply the knowledge and
work
involved in agriculture and
X acquired by him in towns and .
don of the villagers. Wnn
how it affects the worker. He
student the future diK® JgK
bigger hospitals to meet the needs
must be made aware of possible
develop training-cum-sug1’»
of the rural areas and peasant
accidents on the farm and of the
society. Since the training of the
ability by means of prac
diseases arising from poisoning
S the specialist, etc., should
rises in training prog*
and zoonoses’. The Committee
Z____ 1___
local auxiliary health wor^W
be different from the tfammgofdhe
also recommended intensive train
blsic doctor, medical education o
student should receive
o
«
ing programme
at a postgraduate
the aim and purpose of n^^^
the basic doctor in the climca! years
level for those who take up position
. education measures ana
may be conducted in rural settings
nrotAN JOOTNAL OF MEDICAL EDUCATION
I
and amongst peasants.
&
of responsibility fcr health affecting
the agricultural communities. Such
training may be given in Univer
sities or Schools of Public Health or
Institutes of Occupational Health.
The Committee also felt that there
was need for periodic refresher
courses, for all personnel interested
with the health of the peasants
either as long courses of several
weeks, week-end courses and se
minars at demonstration farms or
even correspondence courses. It
also recommended that research in
the subject of Occupational Health
of Agricultural Workers should be
promoted and gave a list of im
portant fields for intensive research
in specialised institutes of Agricul
ture Medicine.
Conclusion
From 1870, the British rulers had laid great
emphasis on ‘Rural Education’,
he., elementary education for the
masses of the people and at the
beginning of this century, Lord
Curzon shifted the emphasis to the
education of the masses through the
medium of vernacular, as an anti
dote to ignorance and to make the
common people happier and more
useful members of the ‘body poli
tic’. As early as 1881, Sir Richard
Temple pleaded before the Indian
Planning Commission that the
agricultural classes should be
started in all grades of schools.
During the last three or four de
cades, attempts have been made to
impart health education not only
in schools but also to the neo
literates and to the peasants.
Brayne recommended compulsory
teaching of sanitation and hygiene,
personal and domestic, to the
peasants and also urged the train
ing of Village Officers in Health
Education and the use of ‘carriages’
in trains for health propaganda.
Onl/a basic doctor, recruited and trained
on the lines indicated above, can succeed in
imparting health education, protect health
or alleviate suffering and rehabilitate the
peasants of India.
- Media
RF_MP_8_G_SUDHA.pdf
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