Must Reads: Medical Nemesis

I've been reflecting recently on some of the books I've read as a medical student apart from our volumnious textbooks and I think it would be interesting to start a series on this blog about essential additional reading for any medical student particularly in the Indian context.

I think the hands down winner for Most Influencial Book is Medical Nemesis: The Expropriation of Health by Ivan Illich simply because it humbles you. In an atmosphere where doctors are becoming sickening self-congragulatory about the increasing use of technology in medicine which enables us to intervene and control bodily phenomena like never before, Illich reminds us that medicine, just like everything else has is limits beyond which is cannot hope to do good. Here is a sample.

Increasing and irreparable damage accompanies present industrial expansion in all sectors. In medicine the damage appears as iatrogenesis. Iatrogenesis is clinical when sickness and death result from medical care; it is social when health policies reinforce an industrial organisation which generates ill health; it is structural when medically sponsored behaviour and delusions restrict the vital autonomy of people by undermining their competence in growing up, caring for each other and aging or when medical intervention disables personal responses to pain, disability, impairment, anguish and death.

The book was first published in the 1970's and is sadly almost unknown among medical circles today. I have still not found a bookshop in India that stocks it though it is available on amazon.com. I myself had to fall back on the time honoured technique of photocopying the only remaining library copy. Read it.

The social context of Indian medicine

I'm currently posted in Chamrajnagar, a rural district in South Karnataka and am practising in a social setting that gives me a lot of food for thought ..

Indian medical practice is largely based on clinical research conducted in the West. Most of the internationally recognised standard texts are by North American or European authors. The teaching methodology used here is largely an outdated, didactical approach which was imported here in the 50’s and 60’s when a large number of medical colleges were set up post independence.

However the social context in which our system is embedded is radically different from the one on which our system is based. While the Westernised elite are more likely to demand and have access to health care it is the poor, who are in an overwhelming majority who really require good, relevant health care. This is because poverty is intrinsically linked to sickness, a large component of which is preventable or easily curable.

It is quite evident that a majority of doctors respond to this difference between theory and reality with a range of practical modifications which range from the simple and obvious to the highly sophisticated. However they still exist only at the level of individual endeavors and as yet there is no large systemic acceptance and addressal of our unique reality.

Doctors in India are also handicapped in their understanding of the social context in which they practice for two reasons: One is that since entrance to medical colleges is highly competetive and students from private schools have an enormous advantage during entrance exams, doctors as a group come predominantly from upper class, upper caste backgrounds whereas a majority of people in real need of health care come from lower class, lower caste backgrounds. The second reason is that since admission to medical college is open to students only from science streams in India, doctors complete their education with only a miniscule component in social sciences as part of their Preventive and Social Medicine syllabus which exists more for namesake than anything else. Hence they are ill equipped to analyse, research and act upon any problem that is not quantitative and out of the realm of pure science.

It is this lack of understanding of social context that has prevented modern Indian medicine from being truly relevant in rural India, where the medical need is immensely greater than in urban areas. The crying need of the day is for Indian doctors to move out of the biomedical paradigm and become anthropologists, communicators and true practioners of revelant social medicine.

Pixels

Thanks to Snake Anthony I have finally managed to put a whole lot of my pictures online on Flickr. Check them out here.

A mere two Israeli generations ago

"In Germany first they came for the communists
and I did not speak out-
because I was not a communist.

Then they came for the Jews
and I did not speak out-
because I was not a Jew.

Then they came for the trade unionists
and I did not speak out-
because I was a Protestant.

Then they came for me-
and there was no one left
to speak out for me."

-Pastor Martin Niemoller (1892-1984)
A leader of the church's oposition to Hitler.

Travelling in the Narmada Valley ..

What did you do when the poor
suffered, when tenderness and life
were dangerously burning out in them?

Apolitical intellectuals
of my sweet country,
you will have nothing to say.

A vulture of silence
will eat your guts.
Your own misery
will gnaw at your souls.
And you will be mute
in your shame.

-Otto Rene Castello.
Guatemalan poet who was killed by the Guatemalan army on March 19, 1967.