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.
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.
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.