Title

Notes on a Year of Travel and Reflection

list of authors

Ravi Narayan

Thelma Narayan

extracted text

CHC II

Notess on a year of Travel and reflection
- 1982

Community Health Cell
Centre for Non
Non-formal & Continuing Education
“Ashirvad"
hirvad" 30 St Marks Road: Bangalore 1

Back ground
1. Both of us had been members of staff of a department of Preventive and
Social Medicine of a medical college in South India, since we graduated in
1971 and, 1977 respectively. Both had decided to join the department
following the experience of participating in disaster relief camps during our
internship (Bangladesh refugee relief camps, 1971 and Andhra Cyclone relief
camps 1977-78). The experience brought us in close touch with communities
in acute need and we became interested in the challenges of health care
delivery in the conditions of poverty.

2. During the years 1973 - 1981, the department of Preventive and Social
Medicine of this college passed through a rapid phase of growth in response
to the institution's, renewed commitment to the rural reorientation of
medical education. During this phase seven rural field practice areas were
initiated and an urban network of health and development efforts around the
college, organised. A unit of occupational Health geared to training and
research programmes in the plantations of South India was also established.
A comprehensive rural internship programme as well as a rural orientation
camp for pre-clinical students was evolved. A wide range of informal, basic
and continuing education efforts for community health workers, doctors and
nurses from rural health projects and small hospitals, plantation medical
officers and other plantation health staff were also developed during this
phase.
3. The work was most interesting and the field experience rich and varied. The
leadership of the department and the institution was farsighted and progressive and
most of us in this phase got experience that was not only relevant but very
comprehensive too. Few institutions in this country can boast of the phenomenal
range of programmes that were built up systematically during this phase.
4. However over the years we began to sense a growing alienation which we soon
realised was both conceptual as well as process related.
The conceptual alienation was, with the focus and setting of Preventive and Social
Medicine as a subject in the context of medical care and education. The teaching of
the subject was academic and examination orientated. Numerous
compartmentalized subjects had been put together under its banner. In the absence
of integral links with the teaching hospital and adequate institutional commitment to
effective, community field practice areas, the subject did not succeed in making any
impact on the attitudes of students or faculties of other departments and was

gradually becoming just another subject speciality rather than the means to a more
comprehensive preventive and social orientation of medicine
5. The process-oriented alienation was linked to the mechanism of the growth of the
department. It seemed to us that there was a quantitative growth of staff, facilities,
courses and field practice areas without a qualitative growth in planning, research,
staff enrichment and programme monitoring and evaluation. New and pilot
programmes soon became routinised and due to a constantly changing staff pattern,
the working of the department often became adhoc and one of crisis intervention.
Programmes initiated as means to an attitudinal change, gradually, became ends by
themselves.
6. we soon realised that some of these problems arose from the inability of most
medical college managements to understand and plan effectively for rural/ social
reorientation of medical education
Firstly, this reorientation process was most often misunderstood as the effort of a
single department rather than a concerted efforts of the entire faculty of a medical
·college. The stress was, therefore, on programmes by PSI1 department rather than
innovative modifications in the teaching, service and research efforts of clinical and
all other departments
Secondly, there was always a dichotomy between the investment and inputs into a
clinical ward and those planned for, in a community field practice area or community
ward. This was not only in terms of available senior faculty but also in terms of
supportive staff, facilities and budgetary sanctions
Thirdly there seemed to be insurmountable obstacles in linking the community field
practice area with the teaching hospital in an effective referral services complex as
envisaged by the Government of India report on Medical Education and Support
Manpower (Shrivastava, 1975)
Fourthly the needs and exigencies of transportation by a community medicine
department team was an area of much misunderstanding.
Fifthly, in the absence of a perspective plan to commit adequate resources to a field
practice area, to enable a team of staff to live in the area and evolve an effective
community programme to be used for teaching purposes, much of the staff
involvement in the community was remote control, tending towards 'armchair
community medicine
In spite of the fact that the thrust in these years was very much towards a process of
rural reorientation all these factors continued to play their part in the evolving
situation even in this college.

7. Of all the programmes mentioned earlier, it was the informal training of community
health workers, alumni doctors from rural hospitals, nurses from rural dispensaries
and plantation medical officers, that gave us maximum job satisfaction and a sense of
fulfillment. These training programmes gave us adequate scope for experimenting
with non-formal and innovative training methodologies using a group dynamic,
problem solving approach. Supporting such groups, who would actually be
undertaking work in the community, seemed more fulfilling than preparing medical
students or nurses for an examination. This informal, alternative experience also
helped us in becoming critically aware of the inadequacies of our didactic, rather
compartmentalized medical education system
8. Over the years we also gradually moved in our understanding of health from its
historic medical connotation of sickness caret to the broader, positive definition of
physical, mental and social well being. We became more aware of the socio-cultural
and political determinants of a health system and its close links and interactions with
the development process. It seemed to us that whereas the medical profession
would continue to map the overflow of preventable illnesses through curative
measures, serious health professionals and workers should and could initiate
processes to turn of the tap of disease and ill health at its very origins in the
individual’s life style, attitudes, family life, community life and environment
As these ideas began to dominate our thinking we began to get more interested in a
wide range of areas and issues not covered by orthodox medical education, viz.,
alternative approaches to health care; issues related to development and sociopolitical change; team building and group dynamics; informal and non-formal
pedagogy, non-drug positive health therapies; Don-allopathic systems of medicine
including folk medicine; cross cultural conflicts in medicine; holistic health and so on
All this supported a paradigm shift within our own perspectives from 'sickness care:
to 'health'
9. Inevitably an active involvement with the field realities of urban and rural field
practice confronted us with social issues of poverty, inequality and injustice. This
confrontation of value systems, life styles, attitudes and modes of team functioning
and decision making was at both a team level and a personal level. Swinging between
the mat-level simplicity of the rural centers and the ivory towered affluence of the
college and hospital was a constant tension. Working with and among rural people
also heightened our sensitivity to the impersonal and dehumanising medical culture
of our large, highly westernised model of college and teaching hospital. It also made
us more than aware of the cross cultural conflicts that the poor patient experiences
when he visits the hospital from a rural areas or urban slum.

10. Over the years our interest in the newer dimensions of health brought us in contact
with a large number' of groups and agencies like the medico-friend circle, Voluntary
health association of India, SEARCH, Indian Social Institute, Society of Young
Scientists, Science for the villages, CREST and Family Welfare Centre, ASTRA of Indian
Institute of Science, Oxfam, Lokayan, Catholic Hospital Association of India, CMAI and
Asian Community Health Action Network. We participated as members or resource
persons in meetings and networking sessions. The awareness of the large numbers of
people committed to health work outside the formal governmental or university
network was a great support.
11. In 1981, some arbitrary decisions by the University affecting the student community
led to a crisis in the college. During this period we had opportunity to organise a
solidarity movement to raise public opinion and the general consciousness of the
campus residents on such arbitrariness of authorities. Apart from gaining some
experience of the dynamics of organising such a collective action, it also gave us an
understanding of the types of motivation of staff and students on the campus. At a
deeper level we understood even a greater evolving crisis that the institution was
running into-- in which the dimensions of lack of communication and motivation; lack
of continuity in processes of planning and decision making; lack of participatory
decision making; lack of inculturation and value formation; and pursuit of excellence
out of context of the pursuit of social relevance were going to play an increasing part.
12. All the above factors led to a certain degree of work related personal frustration and
an increasing desire to rethink our role in medical education and health care. We
therefore decided to 'drop out' of the college for a year and spend ,it visiting health
and development projects in the country, meeting friends, colleagues, and
community health workers, as a process of reflection and evaluation of, our own
personal work experiences and perspectives since graduation.

Overview of 1982
13. The year 1982 with all its component activities was a rich and meaningful experience
for both of us at a personal level and well served its main purpose. We visited a
whole range of field projects and met committed people from different ideological
backgrounds which helped to widen our horizons. The contact with a wide circle of
people actively searching for ways and means by which health and development
could be more meaningful for people especially the rural and urban poor was
inspiring.
We met alumnus of our college working in small rural mission hospitals and reflected
together on some of the inadequacies of the medical education in our alma mater

with specific reference to challenges of rural hospital practice.
We met community health workers in their own project setting and observed the
successes and failures of our training programmes. We identified pressures that
where pushing individual CHWs beyond their capacity. We also become aware of the
deviations from our training as well as its overall limitations especially when
individuals were working out of context of a supportive infrastructure.
We met medico-friend-circle colleagues and a whole range of health and
development activists who were involved with evolving a wide range of alternative
projects and processes with the people. In our discussions with them, we focused on
understanding their work in a process sense as it evolved through positive and
negative experiences. The interactions gave us a rich feed back of the imperatives of
health and development work in our social reality.
We read and reflected on many issues concerning our vocation in greater depth than
had been possible in the earlier years. We searched for answers to many technical
and social questions facing us and though we did not always arrive at a definite conclusion, we discovered points of contact with the experience of others and identified
processes through which more meaningful answers could be obtained.
14. Being a personal quest, the effects of which we hoped would be reflected in our
future work, we did not plan to write a formal report for the institution as such.
However, we list out here some broad perspectives which evolved as learning
experiences from the year. It is impossible to share the whole experience just in a
few paragraphs but the following perspectives highlight the salient conclusions of the
search.

Some perspectives
15. The positive physical, mental and social dimensions of health, both at an individual
and community level have failed to capture the imagination of the medical
professionals and medical educationists because of their historical pre-occupation
with Sickness care.
Years of a floor mopping' attitude to the overflow of disease has resulted in what has
been described as 'highly sophisticated curative practices along with all the
paraphernalia of mystification, professionalisation and total submission to the
dictates of the drug industry
The new 'tap turning off' attitudes in response to the people's needs as well as
potential available knowledge consisting of such ideas as

#
#
#
#
#
#

Primary health care;
Health education;
Demystification of medicine;
Popularization of health producing activities and attitudes;
Strengthening of people1s traditions of self care;
Community organization and participation in health care

and so on therefore continue to be viewed with suspicion, resentment and
intellectual opposition
The ethos of medical care and education, in rurally oriented medical colleges like
ours and others we visited during the 1982 trip as well as in most of the health
services under non-governmental voluntary agency auspices continue to reflect this
myopic medical view
16. Ill health in the ultimate analysis is a direct product of an unjust socio-economic
political system which results in poverty and in equity of resources and opportunities.
A health Team/ heath project health institution, if it’s clear in its health objective
should inevitably become a part of development process which seek solutions for
issues of social justice Of which illness or disease are but a symptom. Health work
should therefore become a development of alternatives by which this process of
democratization is extended to the grass roots enabling people to shape and run
their own structure as a pre requisite. Hospitals dispensaries, medical colleges and
academic health departments which are products of existing structures need much
internal change before they can participate in such process. For a start they need to
become less hierarchical, less elitist and more sensitive to the people, especially the
poor and more participatory.
17. Those of us who function at technological levels in our professional capacities need
to respond creatively to people's needs and evolve alternative and appropriate
frameworks of technology, manpower, processes and communication, within the
constraints in which our people live. Mobile clinics, rural camps, hospital outreach
programmers and other such ideas which get doctors/nurses out 'of institutions into
the realities of rural village and urban slum life are therefore only means. The ends
being the adaptation of specialized knowledge and technical skills to the situation of
people’s lives
18. Especially in medical colleges when such ideas are experimented with as part of a
rural reorientation process, it is crucial to ensure that they are evolved through a
flexible process which stimulates voluntarism and creativity. Otherwise what has
happened in most situations is the thrusting of frustrated, resentful faculty into a

situation outside a hospital setting where they dish out limited st0ck of pills to a
curious general public. Each department needs to understand the levels of care in the
health pyramids, the types of workers available and adequately reorient their own
teaching to “the best possible use of these resources under each circumstance” rather
than “the pursuit of an ideal un-related social reality”.
As examples of this flexible, creativity one may suggest initiatives such as:# Pre-clinical department faculty organizing human biology teaching in village
schools;
# An OBG Department organizing learning sessions for dais and ANMs;
# An anesthesia department experimenting with simple procedures for field
anesthesia including acupuncture;
# A plastic surgery department organizing a burns prevention education
programme in a village school;
A mobile clinic programme would then become a means to such creative
reorientation and as and when each department identifies a more concrete, more
socially relevant role in the community. Only if such creative interactions and
freedom of innovation is made possible; can medical college faculty ever grow out of
their ivory towered isolation. It must be kept in mind that social community
orientations is a first step towards the preventive and promotive reorientation of
medical roles.
19. It is common place for professional institutions to talk of social relevance, rural
reorientation and so on. However, more often than not these have been attempted
by a whole series of adhoc, un-integrated activities representing ideas of individuals
rather than a thoughtfully analysed, planned process of change involving collective
discussions of faculty.
Changes in attitudes, 0bjectives and even professional direction can be brought
about only if the institutional management or team leaders are sensitive to process.
This is as true of rural projects, small peripheral hospitals, large specialist hospitals or
even a medical college. A' social reorientation of its activities and objectives can
evolve gradually through the acceptance of a need for:
# an understanding of the historical process and growth of an
institution/profession/ activity;
# the overall social context in which it operates and the new values or vision it
wants to move towards,
# a setting of clearly defined, measurable objectives;
# a participatory planning process which involves formal and informal feedback
and evaluation as an integral component;

# a team building approach in decision-making; a stress en the development 0f
the human resources of the team rather than material resources and
structures
# a shared value system which shapes attitudes and evolves practice of
individuals within the institution/project
During the year of travel we come across some institutions and projects who were
going about this social reorientation in a serious systematic way and it was through
an interaction with them that we understood .all the components of such a process
20. Team work, professional, or social in any endeavor decides ultimately its success or
failure. This was an important learning experiences Many programmes though
committed to health in community had not internalised "healthy team" functioning
within their structure and the effects of this incongruence were obvious. Highly
individualised efforts pushed in a non-participatory set up were not uncommon
where of orientation to achievement, overshadowed team development, ultimately
sensitive to this dimension, having arrived at its need not always without a crisis in
the project/team. However, by realigning the objectives and methodology so that
team members were enabled, enriched and actively encouraged to participate, they
were beginning to move towards more integrated: efforts. This dimension was as
true of the interaction between team members the interaction between the team
and villages or the community. A partnership in development if it has to be truly in a
spirit of dialogue must go beyond divisions of professional/non- professional
expert/lay, educated/illiterate, medical/non-medical, provider/beneficiary and so on.
That this was happening at least in some projects was a good experience to observe.
Some aspects of this team work that we collected from various experiences was;
# an evolution of mutually shared common objectives. and roles through group
work;
# a concentration on strengths of individuals rather than weaknesses
# an increasing opportunity for sharing of ideas, feelings, hopes and
experiences
# a constant effort to internalise a shared value system ego in community
health oriented efforts this may include healthy life styles and attitudes,
community feeling, simplicity, non-hierarchical functioning, learning from the
people, adapting technology etc
# an informality and openness in inter-personal relationships
# a commitment to learning from field experiences of the entire team rather
than just "theory". This would automatically mean a commitment to constant
experience analysis, critical reflection and review
# an inculcation of participatory management in planning and decision making

Though much of this may seem unrealistic at first, in our present highly
institutionalised set up we discovered through interactions with, even institutionally
based people that institutions or structures by themselves were not stifling or
limiting of such a process.
The major block was the formality of ideas with which individuals and decision
makers choose to function with-in them. It was thus an attitudinal constraint not a
structural one.
21. One of greatest dangers to any social change, reorientation relevance seeking
endeavor is a rapid setting in of institutionalization include:
#
#
#
#
#
#
#
#

Routinisation of activities; ,
Formalisation of functions/relationships;
Increased red-tape;
Fixity of roles;
Fear of precedence;
Discouragement of disregard for informal and formal feed back;
Lack of adequate communications;
Inability of leadership to encourage, enrich and support team members

What was surprising was that many people saw team work' as a genetic attribute of
individuals not an environmentally stimulated response However, many others had
discovered that "good teamwork" does not Just happen. It needs to be planned for
and worked for. We even met teams who were moving from a phase of hierarchical
functioning to a phase of participatory functioning patiently relearning attitudes and
seriously questioning past modes of functioning. That this was possible was
heartening.
22. Having been part of a phase rural re-orientation of medical college before we
embarked on this year travel and reflection, we could not help but critically review
and reflect on the process we had been part of. Some overall perspectives that that
emerged were
a. Rural reorientation of medical education is a term that needs to be changed
since the need is not just to focus on a geographical setting as an end in itself
but to focus on social-economic and cultural functions on socio economic and
cultural factors and issues relevant to health care these are important in the
context of context of the community interaction outside the hospitals but are
equally important factors within the context of hospital functioning. The effort
thus becomes a social and community orientation of all aspects of an
institution's efforts

b. The focus of efforts must not be to get Staff and students to just physically
move into rural areas as an educational or service effort but to challenge and
change attitudes within the profession and institution Stimulated by the
perceptions from the community experience. These attitudes would include :# desire to humanise hospital environment by humanising medical
team-patient relationships,. and improving medical team-patient
communications;
# encouraging demystification of medical knowledge and health
education;
# increasing sensitivity of hospital staff to conditions of poor
patients, the socio-economic factors under which they operate and
the cultural realities of their lives;
# making our technology subservient to people's needs - not making
people subservient to professional; technical, institutional needs.
The latter is possible only through a continuing system of social
audit of institutional services.
c. Such attitudinal changes which is the crux of all our efforts can seldom be
brought about by orders, bonding, pressures, monetary incentives, or indirect
coercion or disincentives even though each of this may have a temporary
effect.
The change can be brought about only by
# increasing role models in the institution by better staff selection;
# open discussion and democratic decision making; ,
# a constant and continued exposure of faculty and students to all
those already involved in such work
# ana1ysing of positive and negative field experiences through a
problem solving approach;
# a creative and flexible encouragement to all suggested initiatives
by faculty
d. An attitudinal change is a sensitive process and is one area where the
counter-productivity of hastily applied, impractical, irrelevant often superimposed methods should be constantly kept in mind and avoided, eg.,
inadequately prepared or unsupervised field exposure, planning insensitive
to the communities' feelings and needs, publicity consciousness in efforts
and so on. Such efforts often result in a growing cynicism which is more
difficult to tackle in the long run
23. It is important to record here that these perspectives were gained visiting people

working both "within formal and informal institutions, projects and networks in
health, development and' education. In all of them there healthy dialogue of whether
existing team/institutions can really internalise some of these newer perspectives
and processes within the existing constraints and established relationships and
modes of functioning. In other words, can a medical college, a department of an
existing institution a technology or specialist oriented hospital, a curative oriented
peripheral hospital even bureaucratized health project, actually change their
attitudes to support and build people's health,' and people's initiatives to gain
greater autonomy over the structures/processes in society that can promote their
health?
Can existing ethos and frames of references of medical institutions change so that
rather than continuing as "providers of medicine" they could, become “enablers of
health”.

Ravi Narayan
Thelma Narayan