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.

We welcome your comments at letters@scroll.in.
Sponsored Content BY 

India’s urban water crisis calls for an integrated approach

We need solutions that address different aspects of the water eco-system and involve the collective participation of citizens and other stake-holders.

According to a UN report, around 1.2 billion people, or almost one fifth of the world’s population, live in areas where water is physically scarce and another 1.6 billion people, or nearly one quarter of the world’s population, face economic water shortage. They lack basic access to water. The criticality of the water situation across the world has in fact given rise to speculations over water wars becoming a distinct possibility in the future. In India the problem is compounded, given the rising population and urbanization. The Asian Development Bank has forecast that by 2030, India will have a water deficit of 50%.

Water challenges in urban India

For urban India, the situation is critical. In 2015, about 377 million Indians lived in urban areas and by 2030, the urban population is expected to rise to 590 million. Already, according to the National Sample Survey, only 47% of urban households have individual water connections and about 40% to 50% of water is reportedly lost in distribution systems due to various reasons. Further, as per the 2011 census, only 32.7% of urban Indian households are connected to a piped sewerage system.

Any comprehensive solution to address the water problem in urban India needs to take into account the specific challenges around water management and distribution:

Pressure on water sources: Rising demand on water means rising pressure on water sources, especially in cities. In a city like Mumbai for example, 3,750 Million Litres per Day (MLD) of water, including water for commercial and industrial use, is available, whereas 4,500 MLD is needed. The primary sources of water for cities like Mumbai are lakes created by dams across rivers near the city. Distributing the available water means providing 386,971 connections to the city’s roughly 13 million residents. When distribution becomes challenging, the workaround is to tap ground water. According to a study by the Centre for Science and Environment, 48% of urban water supply in India comes from ground water. Ground water exploitation for commercial and domestic use in most cities is leading to reduction in ground water level.

Distribution and water loss issues: Distribution challenges, such as water loss due to theft, pilferage, leaky pipes and faulty meter readings, result in unequal and unregulated distribution of water. In New Delhi, for example, water distribution loss was reported to be about 40% as per a study. In Mumbai, where most residents get only 2-5 hours of water supply per day, the non-revenue water loss is about 27% of the overall water supply. This strains the municipal body’s budget and impacts the improvement of distribution infrastructure. Factors such as difficult terrain and legal issues over buildings also affect water supply to many parts. According to a study, only 5% of piped water reaches slum areas in 42 Indian cities, including New Delhi. A 2011 study also found that 95% of households in slum areas in Mumbai’s Kaula Bunder district, in some seasons, use less than the WHO-recommended minimum of 50 litres per capita per day.

Water pollution and contamination: In India, almost 400,000 children die every year of diarrhea, primarily due to contaminated water. According to a 2017 report, 630 million people in the South East Asian countries, including India, use faeces-contaminated drinking water source, becoming susceptible to a range of diseases. Industrial waste is also a major cause for water contamination, particularly antibiotic ingredients released into rivers and soils by pharma companies. A Guardian report talks about pollution from drug companies, particularly those in India and China, resulting in the creation of drug-resistant superbugs. The report cites a study which indicates that by 2050, the total death toll worldwide due to infection by drug resistant bacteria could reach 10 million people.

A holistic approach to tackling water challenges

Addressing these challenges and improving access to clean water for all needs a combination of short-term and medium-term solutions. It also means involving the community and various stakeholders in implementing the solutions. This is the crux of the recommendations put forth by BASF.

The proposed solutions, based on a study of water issues in cities such as Mumbai, take into account different aspects of water management and distribution. Backed by a close understanding of the cost implications, they can make a difference in tackling urban water challenges. These solutions include:

Recycling and harvesting: Raw sewage water which is dumped into oceans damages the coastal eco-system. Instead, this could be used as a cheaper alternative to fresh water for industrial purposes. According to a 2011 World Bank report, 13% of total freshwater withdrawal in India is for industrial use. What’s more, the industrial demand for water is expected to grow at a rate of 4.2% per year till 2025. Much of this demand can be met by recycling and treating sewage water. In Mumbai for example, 3000 MLD of sewage water is released, almost 80% of fresh water availability. This can be purified and utilised for industrial needs. An example of recycled sewage water being used for industrial purpose is the 30 MLD waste water treatment facility at Gandhinagar and Anjar in Gujarat set up by Welspun India Ltd.

Another example is the proposal by Navi Mumbai Municipal Corporation (NMMC) to recycle and reclaim sewage water treated at its existing facilities to meet the secondary purposes of both industries and residential complexes. In fact, residential complexes can similarly recycle and re-use their waste water for secondary purposes such as gardening.

Also, alternative rain water harvesting methods such as harvesting rain water from concrete surfaces using porous concrete can be used to supplement roof-top rain water harvesting, to help replenish ground water.

Community initiatives to supplement regular water supply: Initiatives such as community water storage and decentralised treatment facilities, including elevated water towers or reservoirs and water ATMs, based on a realistic understanding of the costs involved, can help support the city’s water distribution. Water towers or elevated reservoirs with onsite filters can also help optimise the space available for water distribution in congested cities. Water ATMs, which are automated water dispensing units that can be accessed with a smart card or an app, can ensure metered supply of safe water.

Testing and purification: With water contamination being a big challenge, the adoption of affordable and reliable multi-household water filter systems which are electricity free and easy to use can help, to some extent, access to safe drinking water at a domestic level. Also, the use of household water testing kits and the installation of water quality sensors on pipes, that send out alerts on water contamination, can create awareness of water contamination and drive suitable preventive steps.

Public awareness and use of technology: Public awareness campaigns, tax incentives for water conservation and the use of technology interfaces can also go a long way in addressing the water problem. For example, measures such as water credits can be introduced with tax benefits as incentives for efficient use and recycling of water. Similarly, government water apps, like that of the Municipal Corporation of Greater Mumbai, can be used to spread tips on water saving, report leakage or send updates on water quality.

Collaborative approach: Finally, a collaborative approach like the adoption of a public-private partnership model for water projects can help. There are already examples of best practices here. For example, in Netherlands, water companies are incorporated as private companies, with the local and national governments being majority shareholders. Involving citizens through social business models for decentralised water supply, treatment or storage installations like water ATMs, as also the appointment of water guardians who can report on various aspects of water supply and usage can help in efficient water management. Grass-root level organizations could be partnered with for programmes to spread awareness on water safety and conservation.

For BASF, the proposed solutions are an extension of their close engagement with developing water management and water treatment solutions. The products developed specially for waste and drinking water treatment, such as Zetag® ULTRA and Magnafloc® LT, focus on ensuring sustainability, efficiency and cost effectiveness in the water and sludge treatment process.

BASF is also associated with operations of Reliance Industries’ desalination plant at Jamnagar in Gujarat.The thermal plant is designed to deliver up to 170,000 cubic meters of processed water per day. The use of inge® ultrafiltration technologies allows a continuous delivery of pre-filtered water at a consistent high-quality level, while the dosage of the Sokalan® PM 15 I protects the desalination plant from scaling. This combination of BASF’s expertise minimises the energy footprint of the plant and secures water supply independent of the seasonal fluctuations. To know more about BASF’s range of sustainable solutions and innovative chemical products for the water industry, see here.

This article was produced by the Scroll marketing team on behalf of BASF and not by the Scroll editorial team.