Medical research

Why do Indian medical institutions produce so few research papers?

Science and service have retreated under the onslaught of the market.

A recent paper published by a group of researchers from Delhi has been the subject of much public and media debate. The study, which maps the research output from India’s allopathic medical institutions recognised for teaching and training, comes out with some startling findings. The most shocking statistic is that over the last ten years, 332 out of the 579 medical teaching institutions in the country have not produced a single research paper.

The authors of the paper used Scopus, a standard international database, to analyse all published papers and conference proceedings from these institutions. They counted the number of papers and ranked institutions accordingly. The line-up of institutions with high output is predictable. In the category of public institutes, for example, All India Institute of Medical Sciences in Delhi and Postgraduate Institute of Medical Education and Research in Chandigarh top the list.

In the category of private institutions, Gangaram Hospital (the institute to which the authors belong) tops the list. The research paper also informs us that the southern states produce the least number of papers despite having the most number of medical colleges.

In what is perhaps an inappropriate comparison, the authors pit the number of papers produced by leading medical institutions in the US against the top Indian performers. Unsurprisingly, the gap is huge.

Interestingly, they describe how research output from China has grown leaps and bounds in the last few decades and is now well above India. The authors, however, fail to enlighten us on how the Indian institutions perform in comparison to their South Asian counterparts.

Unsurprising finding

That said, the big story is that while the number of medical colleges in India has grown exponentially, there is almost no published research work from many institutions where hundreds of postgraduate students write a thesis for their exams.

In other words, if the output of published papers is indeed taken as a bellwether, research in Indian medical colleges is abysmally low. As someone who has taught in medical institutions in Mumbai – both in the public and private sector – for the last two decades, I am not particularly surprised by these findings.

Even though the public institution I trained at and the private institution I work in both figure among the top 25, I must confess that I am unable to convince more than half of my own postgraduate students to convert their thesis work into papers.

The authors of the research paper attempt to point out some of the reasons that are often advanced to explain this anomaly, and suggest that most of these are excuses. In the concluding part rather grandiosely titled “What is to be done?”, they suggest some rather tame solutions. The predominant one is a call to commission an Indian version of a 1910 report from the US called the Flexner Report, which apparently changed the scenario in the US.

There has been the customary shock and dismay in response to the paper, with the international media also joining the collective lament. It’s only a matter of time before some politically correct sound bites from the government are heard. And perhaps another committee may be conjured up. Most likely, though, like many other things, this shall too pass.

Career motives

At another level, however, the low output of research papers is a serious issue because it is a harbinger of something much bigger, with implications for healthcare delivery. This phenomenon may be better understood by scraping beneath the surface and understanding some fundamental issues.

A good place to start would be asking why a young student in contemporary would take up a medical course. What are the typical ambitions? The answer is loud and clear.

A medical career in India today is largely about financial aspirations and seeking a “good life”. It’s also a matter of status, including value in the marriage market.

Another consideration is dynasty and an investment returns equation, wherein medical education is seen as a solid investment with guaranteed returns. This also explains why parents cough up humongous sums of money to get their kids into private medical colleges of dubious training value. For that matter, even a certain complicity of parents in Madhya Pradesh’s infamous Vyapam scam is owing to this calculation. Thus, very few students actually take up a medical career essentially out of a sense of scientific inquiry.

Further, given the liberalised economy and the burgeoning private sector in medicine, the goalposts for most young medical students have shifted to the highly monetised world of corporate medicine. Therefore, the process of medical education is very end-oriented, with the final aim being certain lucrative areas of work. This also explains why careers in radiology and cosmetic surgery are now in huge demand at the postgraduate level.

No real incentive

This aspiration may not be unique to India, although in many countries where a nationalised health system means fixed salaries, students aspiring for big money typically don’t enter the medical field for the payout.

In some countries including the US, there is significant space and recognition for research and teaching activity as an alternative to private practice. You could even say that scientific pursuit has been made glamorous and cool.

In the Indian scenario, as things stand, the ultimate ambition for most students finishing undergraduate studies is to do a postgraduate degree that will culminate in a lucrative job in the private sector. This sector has no serious interest in research credentials. While appointing medical staff, very few private sector institutions in India demand any research background. For that matter, appointments are largely made on the ability to attract patients and also on connections, community and influence. All said and done, there is really no incentive for most medical trainees to do any research, as it is disconnected from their career goal. Also, in the aspirational environment, the definition of a successful professional is now centred around numbers and material wealth.

This is not to say that measures aimed at incentivising research activity and increasing funding should not be attempted. The elephant in the room which the authors of the paper fail to acknowledge is the influence of the uniquely unregulated and monstrous private sector in Indian healthcare, which essentially appeals to the entrepreneurial instincts of doctors. Science and market medicine don’t sit well together.

The big picture

In the Indian psyche, there is also the additional confounder of a heady nostalgic discourse on our apparent scientific achievements in healthcare in some bygone era. Even the prime minister is unable to resist the temptation to dig into mythology, using Lord Ganesha as a reference to talk about our skills in plastic surgery.

Finally, there is also the valid question of whether just writing papers constitutes quality research relevant to the problems faced in Indian healthcare, especially public health. A lot of observational and policy changing work done by public health-oriented doctors working in underserved areas is actually research germane to Indian conditions. For example, the work of Binayak Sen in documenting malnutrition among children in Central India is not extensively published, but is in some ways research of the highest order.

While the authors of the paper have done a good job in raising an important gap in Indian healthcare, viewing it in isolation and suggesting patchwork solutions may be disingenuous. On the other hand, if we choose to join the right dots and utilise the data as yet another marker of the larger crisis of healthcare, which is the retreat of science and service under the onslaught of the market, we may move towards more difficult but effective corrective action.

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Removing the layers of complexity that weigh down mental health in rural India

Patients in rural areas of the country face several obstacles to get to treatment.

Two individuals, with sombre faces, are immersed in conversation in a sunlit classroom. This image is the theme across WHO’s 2017 campaign ‘Depression: let’s talk’ that aims to encourage people suffering from depression or anxiety to seek help and get assistance. The fact that depression is the theme of World Health Day 2017 indicates the growing global awareness of mental health. This intensification of the discourse on mental health unfortunately coincides with the global rise in mental illness. According to the latest estimates from WHO, more than 300 million people across the globe are suffering from depression, an increase of 18% between 2005 and 2015.

In India, the National Mental Health Survey of India, 2015-16, conducted by the National Institute of Mental Health and Neurosciences (NIMHANS) revealed the prevalence of mental disorders in 13.7% of the surveyed population. The survey also highlighted that common mental disorders including depression, anxiety disorders and substance use disorders affect nearly 10% of the population, with 1 in 20 people in India suffering from depression. Perhaps the most crucial finding from this survey is the disclosure of a huge treatment gap that remains very high in our country and even worse in rural areas.

According to the National Mental Health Programme, basic psychiatric care is mandated to be provided in every primary health centre – the state run rural healthcare clinics that are the most basic units of India’s public health system. The government provides basic training for all primary health centre doctors, and pays for psychiatric medication to be stocked and available to patients. Despite this mandate, the implementation of mental health services in rural parts of the country continues to be riddled with difficulties:

Attitudinal barriers

In some rural parts of the country, a heavy social stigma exists against mental illness – this has been documented in many studies including the NIMHANS study mentioned earlier. Mental illness is considered to be the “possession of an evil spirit in an individual”. To rid the individual of this evil spirit, patients or family members rely on traditional healers or religious practitioners. Lack of awareness on mental disorders has led to further strengthening of this stigma. Most families refuse to acknowledge the presence of a mental disorder to save themselves from the discrimination in the community.

Lack of healthcare services

The average national deficit of trained psychiatrists in India is estimated to be 77% (0.2 psychiatrists per 1,00,000 population) – this shows the scale of the problem across rural and urban India. The absence of mental healthcare infrastructure compounds the public health problem as many individuals living with mental disorders remain untreated.

Economic burden

The scarcity of healthcare services also means that poor families have to travel great distances to get good mental healthcare. They are often unable to afford the cost of transportation to medical centres that provide treatment.

After focussed efforts towards awareness building on mental health in India, The Live Love Laugh Foundation (TLLLF), founded by Deepika Padukone, is steering its cause towards understanding mental health of rural India. TLLLF has joined forces with The Association of People with Disability (APD), a non-governmental organisation working in the field of disability for the last 57 years to work towards ensuring quality treatment for the rural population living with mental disorders.

APD’s intervention strategy starts with surveys to identify individuals suffering from mental illnesses. The identified individuals and families are then directed to the local Primary Healthcare Centres. In the background, APD capacity building programs work simultaneously to create awareness about mental illnesses amongst community workers (ASHA workers, Village Rehabilitation Workers and General Physicians) in the area. The whole complex process involves creating the social acceptance of mental health conditions and motivating them to approach healthcare specialists.

Participants of the program.
Participants of the program.

When mental health patients are finally free of social barriers and seeking help, APD also mobilises its network to make treatments accessible and affordable. The organisation coordinates psychiatrists’ visits to camps and local healthcare centres and ensures that the necessary medicines are well stocked and free medicines are available to the patients.

We spent a lot of money for treatment and travel. We visited Shivamogha Manasa and Dharwad Hospital for getting treatment. We were not able to continue the treatment for long as we are poor. We suffered economic burden because of the long- distance travel required for the treatment. Now we are getting quality psychiatric service near our village. We are getting free medication in taluk and Primary Healthcare Centres resulting in less economic stress.

— A parent's experience at an APD treatment camp.

In the two years TLLLF has partnered with APD, 892 and individuals with mental health concerns have been treated in the districts of Kolar, Davangere, Chikkaballapur and Bijapur in Karnataka. Over 4620 students participated in awareness building sessions. TLLLF and APD have also secured the participation of 810 community health workers including ASHA workers in the mental health awareness projects - a crucial victory as these workers play an important role in spreading awareness about health. Post treatment, 155 patients have resumed their previous occupations.

To mark World Mental Health Day, 2017, a team from TLLLF lead by Deepika Padukone visited program participants in the Davengere district.

Sessions on World Mental Health Day, 2017.
Sessions on World Mental Health Day, 2017.

In the face of a mental health crisis, it is essential to overcome the treatment gap present across the country, rural and urban. While awareness campaigns attempt to destigmatise mental disorders, policymakers need to make treatment accessible and cost effective. Until then, organisations like TLLLF and APD are doing what they can to create an environment that acknowledges and supports people who live with mental disorders. To know more, see here.

This article was produced by the Scroll marketing team on behalf of The Live Love Laugh Foundation and not by the Scroll editorial team.