India trains quacks to ease shortage of rural doctors
Pioneering project by the Liver Foundation in Calcutta wants to give unlicensed doctors in rural areas some formal training, to help people in places where access to real health care is almost non-existent
There is a gigantic force in India – an estimated 2.5 million strong – of men and women who have picked up snatches of medical knowledge from a homeopath or chemist, or from a relative, or from working as a doctor’s assistant, who prefix “Dr” to their name and start treating patients in the remote village where they live, where there is no real doctor for miles.
For city dwellers, these self-taught men are quacks, perfect specimens of the truism that a little knowledge is a dangerous thing. For Dr Abhijit Chowdhury, professor of hepatology at Calcutta’s Institute of Post Graduate Medical Education and Research, they are fillers of a void – the people who provide an invaluable service to rural Indians who have no access to proper health care and probably won’t for a very long time to come.
The Healthcare Federation of India said last March that India was short of two million doctors and four million nurses. It said about 70 per cent of the health care infrastructure was concentrated in the top 20 or so cities. That leaves a lot of the country out in the cold with not even a syringe in sight.
Chowdhury is founder of the Liver Foundation in Calcutta, a charity that has been training quacks for years, not to become not doctors, but to be better at what they do. The Foundation doesn’t like calling them quacks. It prefers to call them “informal rural health care providers”. “Empirical craftsmen” is another name Chowdhury likes to use.
The foundation’s training programme is based on a simple premise. Rural Indians don’t have access to qualified doctors. The nearest primary health care centre can be more than 30km away and the doctor will probably be absent because medical practitioners shun the idea of working in the countryside.
When villagers fall ill, they turn to the “doctor” in their village, a person who seems to know how to treat routine ailments such as fever, diarrhoea, malaria, anaemia, hypertension, urinary tract infections and so on. They trust him (they are predominantly male). He is available at night, he charges very little and accepts payment in kind if villagers have no money. They know that he helps. What they don’t know is that, at times, by failing to recognise a serious condition, he can harm the patient.
“Our training is based on the realisation that we cannot do without them and cannot wish them away. They offer a vital service for people who have nothing else. Instead of ignoring them or laughing at them, our training helps to improve the work they do and minimise damage,” says Chowdhury, who spearheaded the project.
Dr Partha Sarathi Mukherjee, project director at the foundation, says if the training increases the positive work of quacks by 10 to 20 per cent and reduces their negative impact by 10 per cent, that is a net benefit to their patients. “Instead of ignoring them or ostracising them, we are harnessing their skills,” he says.
The training for rural practitioners has been carried out in four districts of West Bengal (of which Calcutta is the capital) in eastern India. It is carried out over two days a week and lasts nine months. So far, more than 2,000 quacks have completed the training.
The West Bengal government has been so impressed that last month, it decided to throw its weight behind scaling up the project. A state-wide training programme is to start this month to train all of the estimated 170,000 quacks in West Bengal. They will be called village health workers.
The Foundation has trained more than 100 trainers to work in the 33 centres that will be set up. The training comprises basic human anatomy, some theoretical knowledge, pharmacology, diagnosing fevers and infections correctly, the ability to judge when a patient should be referred to a real doctor and the dangers of overprescribing drugs,. The core of the training is “harm reduction”.
They are all given a grey coat to wear for the sessions. A small number are women. “The first thing we make them state formally, out loud, is ‘I am not a doctor,’” says Dr Saibal Majumdar who is in charge of training. “We tell them they have to stop using ‘Dr’. There is a lot of reluctance over this but we explain that they are already respected in their area and can do without it.”
Around 15 to 20 per cent drop out, usually older practitioners who are so well known they think they have nothing to learn. Their most common errors, says Majumdar, are using injections to induce labour; using IVF fluids unnecessarily; overprescribing antibiotics; giving antibiotics for viruses; and lack of awareness about which drugs should not be given to pregnant women.
“Many don’t know that dosage has to be correlated with a patient’s weight. If they were once working as an assistant to a doctor and saw him prescribing a certain dosage, they give the same, even though it’s a paediatric dose for an adult,” says Majumar.
Apart from making them renounce the title of doctor, the second most painful moment for the trainee quacks is not getting what they covet at the end of the training – a certificate. “We deliberately don’t give them a certificate in case they frame it and misuse it to claim that they are proper doctors,” he says.
A World Bank study in October showed mixed results after evaluating both quacks who had undergone the training and regular doctors. It found that although those quacks who had been trained were more likely to adhere to checklists and had improved their treatment, they still prescribed drugs unnecessarily. However, the study showed that regular doctors were 26 per cent more likely to do this than the trained quacks.
A study published last year based on a similar project in the state of Madhya Pradesh showed that quacks tended to spend more time with their patients than doctors and were no worse in their diagnosis and treatment.
For Sanjit Ganguly, 42, who had “practised” his profession for 16 years in a rural area outside Calcutta, before undergoing the training a year ago, the benefits have been numerous. He says he is better at diagnosis and the use of antibiotics.
“But the biggest benefit was understanding my limits. A patient came to me late last night. All his vital parameters were low. He didn’t seem to be in his senses. I told his family to take him to the nearest government hospital without delay. This – knowing when I can’t help – is the most important thing I have learnt,” says Ganguly.